HIV-associated disseminated cryptococcosis-An unusual clinical and diagnostic picture with successful cure by single dose liposomal amphotericin B treatment

BACKGROUND

Cryptococcosis is an invasive, opportunistic fungal infection seen especially in human immunodeficiency virus (HIV) infected patients. Cryptococcal meningitis (CM) is the second leading cause of mortality in HIV patients. We report a case of disseminated cryptococcosis presenting with altered mental status in a newly diagnosed HIV infection.

METHODS AND RESULTS

A 50-year-old with a short history of altered mental sensorium and a history of low-grade fever and weight loss for few months presented at a tertiary care hospital in North India. He was detected positive for HIV-1. Cryptococcal antigen (CRAG) was positive in Cerebrospinal fluid (CSF), and negative in serum. The fungal culture in CSF was sterile while the fungal blood culture grew Cryptococcus neoformans. The patient was treated with single high-dose Liposomal Amphotericin B (LAmB) therapy followed by Fluconazole and Flucytosine for the next two weeks followed by fluconazole daily for consolidation and maintenance therapy. Antiretroviral therapy (ART) was started 4 weeks after induction therapy. After 6 months, the patient is doing fine.

CONCLUSION

Single dose LAmB along with the backbone of fluconazole and flucytosine appears promising in disseminated cryptococcal infection in HIV-infected individuals.

Evaluation of the pharmacokinetics of liposomal amphotericin B and analysis of the relationship between pharmacokinetics, efficacy and safety in patients with hematological diseases

INTRODUCTION

This study aimed to identify factors responsible for changes in blood concentrations of a liposomal formulation of amphotericin B (AMPH-B, L-AMB) and analyze the relationships between blood concentrations and efficacy or toxicity.

METHODS

L-AMB was administered to 30 patients being treated for hematological diseases. AMPH-B plasma concentrations were determined right before the initiation (Cmin) and at the end (Cmax) of infusion on at least 1 day, beginning on Day 3 of L-AMB treatment. The relationships of Cmin divided by dose (C/D ratio) to body weight, age, hepatic function, renal function, serum albumin, C-reactive protein (CRP), response, hypokalemia, and renal impairment were evaluated.

RESULTS

C/D ratio was not correlated with age, hepatic function, renal function, or serum albumin. Body weight adjusted C/D ratio was negatively correlated with CRP. Cmax and Cmin were compared between responders and non-responders, those with or without hypokalemia, and those with or without renal impairment. A higher Cmax in patients with hypokalemia was the only significant difference seen.

CONCLUSIONS

The negative correlation between CRP and plasma concentrations was likely caused by higher distribution of L-AMB from the blood to infected tissue in patients with a greater degree of infection, with a resulting decrease in plasma concentrations. AMPH-B plasma concentrations were not related to response. Higher Cmax of AMPH-B were observed in patients with hypokalemia, but no relationship between plasma concentration and renal toxicity was observed, suggesting that AMPH-B plasma concentrations appear to be minimally related to PD when used as L-AMB.

Postpartum cryptococcosis in an HIV-negative patient

PURPOSE AND METHODS

We present an unusual case of an HIV-negative patient with postpartum pulmonary cryptococcosis and cryptococcemia.

RESULTS

The diagnostic methods and treatment of cryptococcosis in a postpartum patient are presented in this case report. Due to anaphylaxis to liposomal amphotericin B, desensitisation to the drug was performed.

CONCLUSION

We would like to raise awareness about rare infections such as cryptococcosis in pregnancy and the postpartum period. In addition, we were able to document a successful desensitisation to liposomal amphotericin B.

Palatal mucormycosis in a 2-month-old child: A very rare case report and a literature review

A 2-month-old Syrian male child presented with a large blackish ulcerating lesion on his hard palate, along with fever, diarrhea, vomiting, and milk regurgitation from the nose. The child was diagnosed with palatal mucormycosis by histopathology and underwent treatment with liposomal amphotericin B and surgical debridement. However, despite treatment, the child's condition deteriorated, and he died from respiratory failure. An underlying immunodeficiency was not diagnosed, but the family history revealed several deaths of the child's siblings at very early ages due to poorly documented complicated metabolic syndromes. An autopsy was refused by the parents due to cultural reasons.

Survival of a Rhino-Orbital-Cerebral Mucormycosis Patient after Localized Combination Liposomal Amphotericin B Medications: A Case Report

Introduction

The aim of this study was to report a case of ROCM related to nasogastric intubation who was survived by liposomal amphotericin B (LAmB) combination therapy in situ without orbital exenteration.

Case Presentation

A 44-year-old woman presented with a 1-week history of rapidly enlarging swelling on the right nose, cheek, and lower eyelid after underwent gastrointestinal decompression. The lesions were derived from the nasal area where the nasogastric tube had been placed. Based on the biopsy results and clinical manifestations, ROCM was diagnosed. Immediate combination therapy with intravenous LAmB and micafungin and multisection debridement of the right facial region were applied. Postoperative treatment included cleaning, irrigating, and local dressing of the wound area using LAmB. LAmB was also used daily as binocular eye drops against deep infection on the eyeballs. The patient recovered well 4 months later and remained free of disease after 40 months of follow-up.

Conclusion

This case adds to our knowledge on the potential risk of nasogastric intubation for mucormycosis infection. Nasogastric tube may be the source of infection associated with ROCM. This report evaluates the beneficial effect of LAmB combination therapy in situ for cleaning, irrigating, local wound dressing, and eye drops on lesion areas. The combination of LAmB as cleaning, irrigating, local dressing solution, and eye drops to control intraocular and intraorbital ROCM infection has not been previously reported to our knowledge. These methods provide multiple choices to substitute for orbital exenteration on the survival of ROCM patients.

An immunocompetent case of chronic pulmonary aspergillosis caused by Aspergillusviridinutans

We encountered an extremely rare immunocompetent case of chronic pulmonary aspergillosis (CPA) caused by Aspergillus viridinutans. A 74-year-old woman was admitted with fever and hemoptysis. Chest computed tomography revealed a nodule in the left upper lobe. Bronchoscopy was performed, and the transbronchial biopsy specimen revealed Aspergillus fungi. Treatment of the nodule was initially ineffective with voriconazole but effective with liposomal amphotericin B. The causative organism was later identified as A. viridinutans based on the gene sequence of β-tubulin. This is the first immunocompetent case of CPA caused by A. viridinutans.

[Visceral Leishmaniasis in an Immunocompetent Patient: A Case Report]

Leishmaniasis is a parasitic disease transmitted by the bite of female sandflies that occurs in tropical and subtropical climate regions. Visceral leishmaniasis is the most serious manifestation of the disease, leading to a 95% mortality rate after two years of infection if untreated. Visceral leishmaniasis is frequently associated with immunocompromised states, with the human immunodeficiency virus being the most prevalent. Most cases of visceral leishmaniasis are caused by the species Leishmania donovani and Leishmania infantum, the latter being the endemic species in the Mediterranean basin. In Portugal, the number of reported cases of visceral leishmaniasis has decreased in the last few years, with 15 cases reported between 2017 and 2021. The authors present a case of visceral leishmaniasis in an immunocompetent patient who manifested the classic pentad: fever, weight loss, hepatosplenomegaly, pancytopenia and hypergammaglobulinemia. The diagnosis was made by the observation of amastigotes of the Leishmania infantum species in the bone marrow aspirate examination, and the patient was successfully treated with liposomal amphotericin B.

Critical appraisal beyond clinical guidelines for intraabdominal candidiasis

BACKGROUND

Regardless of the available antifungals, intraabdominal candidiasis (IAC) mortality continues to be high and represents a challenge for clinicians.

MAIN BODY

This opinion paper discusses alternative antifungal options for treating IAC. This clinical entity should be addressed separately from candidemia due to the peculiarity of the required penetration of antifungals into the peritoneal cavity. Intraabdominal concentrations may be further restricted in critically ill patients where pathophysiological facts alter normal drug distribution. Echinocandins are recommended as first-line treatment in guidelines for invasive candidiasis. However, considering published data, our pharmacodynamic analysis suggests the required increase of doses, postulated by some authors, to attain adequate pharmacokinetic (PK) levels in peritoneal fluid. Given the limited evidence in the literature on PK/PD-based treatments of IAC, an algorithm is proposed to guide antifungal treatment. Liposomal amphotericin B is advocated as first-line therapy in patients with sepsis/septic shock presenting candidemia or endophthalmitis, or with prior exposure to echinocandins and/or fluconazole, or with infections by Candida glabrata. Other situations and alternatives, such as new compounds or combination therapy, are also analysed.

CONCLUSION

There is a critical need for more robust clinical trials, studies examining patient heterogeneity and surveillance of antifungal resistance to enhance patient care and optimise treatment outcomes. Such evidence will help refine the existing guidelines and contribute to a more personalised and effective approach to treating this serious medical condition. Meanwhile, it is suggested to broaden the consideration of other options, such as liposomal amphotericin B, as first-line treatment until the results of the fungogram are available and antifungal stewardship could be implemented to prevent the development of resistance.

Otitis externa caused by Malassezia slooffiae complicated with mastoiditis: A case report

Herein, we report a case of otitis externa caused by Malassezia slooffiae complicated with mastoiditis. A 70-year-old male complained of fever and severe otorrhea from left external auditory canal 2 months after undergoing a craniotomy to remove a hematoma. He had right-sided paralysis and undertook bed rest. Brain computed tomography revealed continuous fluid accumulation in the left mastoid air cells and middle ear from left external auditory canal in addition to leukocytosis and increased C-reactive protein level. The tympanic membrane was severely swelling. These results indicated the presence of otitis media and mastoiditis. Otorrhea culture showed large amounts of M. slooffiae. The administration of liposomal amphotericin B (L-AMB), the irrigation of external auditory canal with normal saline, and the application of topical ketoconazole ointment were started. The administration of L-AMB for 8 weeks and voriconazole, which was switched from L-AMB, for 4 weeks ameliorated his infection and he was transferred to another hospital to receive rehabilitation. From these results and his clinical course, the diagnosis of otitis externa caused by Malassezia slooffiae complicated with mastoiditis was made. And the possibility of the contamination by M. slooffiae was very low. Clinicians should be aware that M.slooffiae can provoke otological infections since M. slooffiae is the most common Malassezia sp. in external auditory canal.

Surge of mucormycosis during the COVID-19 pandemic

Patients with respiratory viral infections are more likely to develop co-infections leading to increased fatality. Mucormycosis is an epidemic amidst the COVID-19 pandemic that conveys a 'double threat' to the global health fraternity. Mucormycosis is caused by the Mucorales group of fungi and exhibits acute angioinvasion generally in immunocompromised patients. The most familiar foci of infections are sinuses (39%), lungs (24%), and skin tissues (19%) where the overall dissemination occurs in 23% of cases. The mortality rate in the case of disseminated mucormycosis is found to be 96%. Symptoms are mostly nonspecific and often resemble other common bacterial or fungal infections. Currently, COVID-19-associated mucormycosis (CAM) is being reported from a number of countries such as the USA, Turkey, France, Mexico, Iran, Austria, UK, Brazil, and Italy, while India is the hotspot for this deadly co-infection, accounting for approximately 28,252 cases up to June 8, 2021. It strikes patients within 12-18 days after COVID-19 recovery, and nearly 80% require surgery. Nevertheless, the mortality rate can reach 94% if the diagnosis is delayed or remains untreated. Sometimes COVID-19 is the sole predisposing factor for CAM. Therefore, this study may provide a comprehensive resource for clinicians and researchers dealing with fungal infections, intending to link the potential translational knowledge and prospective therapeutic challenges to counter this opportunistic pathogen.

Successful treatment of proven coronavirus disease 2019-associated pulmonary aspergillosis with liposomal amphotericin B in a patient with bronchiolitis obliterans syndrome after allogeneic hematopoietic stem cell transplantation

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is being increasingly recognized as a severe complication that contributes to poor prognoses among patients with COVID-19. However, little is known regarding the clinical course of CAPA with hematological malignancies, especially after allogeneic hematopoietic stem cell transplantation (HSCT). A 29-year-old woman was diagnosed with proven CAPA with an Aspergillus fumigatus identified by cultures of bronchoalveolar lavage and lung biopsy four years after haploidentical HSCT for acute myelogenous leukemia. She had been taking oral prednisolone for bronchiolitis obliterans syndrome that developed after HSCT. Although prolonged RT-PCR positivity for SARS-CoV-2 (133 days after the onset of COVID-19) without shedding of viable virus was observed, the COVID-19 was treated with favipiravir, remdesivir, dexamethasone, and enoxaparin. However, the CAPA did not respond to combination therapy, which included triazole (voriconazole, itraconazole, posaconazole) and echinocandin (caspofungin, micafungin), even though the Aspergillus fumigatus isolate was found to be susceptible to these agents in vitro. Nevertheless, a total of 16 weeks of liposomal amphotericin B (L-AMB) therapy led to a favorable response, and the patient was discharged from the hospital on day 213. This case provided essential experience of CAPA treated with L-AMB in a recipient with chronic respiratory disease after HSCT.

Successful treatment of invasive tracheobronchial pulmonary aspergillosis with venovenous extracorporeal membrane oxygenation and combined systemic, intratracheal instillation of liposomal amphotericin B: a case report

BACKGROUND

Invasive pulmonary Aspergillus and invasive bronchial aspergillosis is a life-threatening opportunistic fungal infection that predominantly affects immunocompromised hosts. A case series and review found that the mortality rate of invasive bronchial aspergillosis is high, at about 40%, and 23.7% of invasive bronchial aspergillosis patients require mechanical ventilator management. There are few reports of life-saving cases with venovenous extracorporeal membrane oxygenation as rescue therapy in invasive pulmonary Aspergillus and invasive bronchial aspergillosis. Here, we report a case of invasive bronchial aspergillosis and invasive pulmonary Aspergillus that was successfully treated with venovenous extracorporeal membrane oxygenation, and combined systemic and intratracheal instillation of liposomal amphotericin B.

CASE PRESENTATION

We present the case of a 61-year-old Japanese man with invasive tracheobronchial-pulmonary aspergillosis while receiving chemotherapy for malignant lymphoma. Bronchoscopy revealed trachea covered with pseudomembranous necrotizing tissue, the culture revealed Aspergillus fumigatus, and the histological findings of pseudomembranous revealed fungal hyphae. The patient required venovenous extracorporeal membrane oxygenation because of respiratory failure for atelectasis and obstructive pneumoniae. While continuing systemic administration of liposomal amphotericin B, intratracheal instillation liposomal amphotericin B was performed by bronchoscopy three times a week. Although the respiratory conditions improved and the patient was discontinued on venovenous extracorporeal membrane oxygenation, he ultimately died of recurrence of malignant lymphoma.

CONCLUSION

Intratracheal instillation of liposomal amphotericin B is safe, and liposomal amphotericin B instillation allowed a targeted high local drug concentration, which led to improvement in the invasive bronchial aspergillosis. In addition, since the patient was supported with venovenous extracorporeal membrane oxygenation, we were able to perform safe bronchoscopic debridement of airway lesions and intratracheal instillation of liposomal amphotericin B.

Successful treatment of rhino-cerebral mucormycosis with dual antifungal therapy and minimal surgical debridement

The authors report the case of a 42-year-old female with history of type I diabetes mellitus and recent episode of diabetic ketoacidosis who presented with symptoms of epistaxis, gastrointestinal upset, hyperglycemia, confusion, and a cough. She was found to have rhino-cerebral mucormycosis with associated multi-focal strokes and a left internal carotid artery pseudoaneurysm. Her infection was successfully treated with dual-antifungal therapy consisting of liposomal amphotericin B and isavuconazole, and required only minimal surgical debridement.

A comparison of liposomal amphotericin B alone and in combination with flucytosine in the treatment of non-HIV Cryptococcal meningitis: A nationwide observational study

BACKGROUND

Cryptococcal meningitis (CM) is an opportunistic infectious disease that occurs in immunocompromised hosts, not only in patients living with HIV, but also in patients without HIV. The evidence regarding the treatment for CM in patients without HIV is mainly found in small retrospective studies and is extremely limited.

OBJECTIVES

In the present study, we compared the efficacy of liposomal amphotericin B (L-AMB) alone and in combination with flucytosine (5-FC) for the induction treatment of CM in patients without HIV.

PATIENTS/METHODS

Data was gathered from the Japanese Diagnosis Procedure Combination database obtained from hospitals throughout Japan. The study included 517 patients without HIV but having CM who fulfilled the inclusion and exclusion criteria. We analyzed the average effect of adding 5-FC to L-AMB treatment using the survival time within 14 days of the diagnosis after adjustment of the baseline clinical characteristics with associations with both selections of the treatment and the prognosis.

RESULTS

A total of 146 and 217 CM patients received L-AMB and L-AMB with 5-FC, respectively, within 7 days of diagnosis. L-AMB with 5-FC showed better prognosis than L-AMB on day 14 (mortality 6% vs. 11%, hazard ratio, 0.5775; 95% confidence interval, 0.2748-1.213; p = 0.1, Wald test).

CONCLUSIONS

From the results of this real-world database study, we revealed that the combination therapy of 5-FC on L-AMB for induction therapy might have an advantage on the survival time of NHNT patients with CM as well as PLHIV patients with CM.

Association between fluid infusions and the recovery from acute kidney injury in patients administered liposomal amphotericin B: a nationwide observational study

Acute kidney injury (AKI) often develops during the administration of liposomal amphotericin B (L-AMB), a broad-spectrum antifungal drug. However, clinical recovery approaches for AKI patients administered L-AMB are not well established. This retrospective analysis used the data obtained from hospitals throughout Japan. AKI was defined as a ≥ 1.5-fold increase within 7 days or ≥0.3 mg/dL increase within 2 days in serum creatinine. AKI recovery was defined as a return to creatinine levels below or equal to those recorded before AKI onset. Ninety patients were assessed for recovery from AKI as per the three stages. The incidence of recovery from AKI regardless of its stage was higher, though not significant, in patients administered ≥10 mL/kg/day fluid for 7 consecutive days from AKI onset (63%) than in those who did not (35%, p = 0.053). However, if limited to AKI stage 1 patients, the former group had a significantly higher incidence of recovery (91%) than the latter group (50%, p = 0.017), even after adjusting for confounding factors (odds ratio: 10.135, 95% confidence interval: 1.148–89.513, p = 0.037). The daily fluid volume administered during the 7 consecutive days from AKI onset positively correlated with the recovery from AKI of all stages (p = 0.043). Daily consecutive fluid infusion from AKI onset may be associated with recovery from stage 1 AKI in patients administered L-AMB, with daily fluid volume positively correlating with the incidence of AKI recovery.

Sinonasal mucormycosis and liposomal amphotericin B: A quest for dose optimization

OBJECTIVES

Sinonasal mucormycosis is a serious fungal infection. Early diagnosis and prompt antifungal therapy along with surgical intervention is the key to its management. Liposomal amphotericin B (LAmB) given intravenously is the antifungal agent of choice. However, the current literature is not clear on its optimum dosage. We did a retrospective study to find the optimum dose of LAmB in cases with sinonasal mucormycosis.

MATERIALS AND METHODS

Thirty patients diagnosed with mucormycosis involving sinonasal, rhino-orbital, or rhino-orbito-cerebral regions and receiving only LAmB as pharmacotherapy were included in our retrospective study from 2017 to 2020. A multiple logistic regression model was developed to correlate the total dose of LAmB and other parameters with the final outcome which was defined clinico-radiologically as improved, worsened, or death. The dose of LAmB which led to the first significant change in urea, creatinine, and potassium levels was also determined.

RESULTS

The model showed a good fit in goodness-to-fit analysis (Pearson = 0.999, deviance = 0.995), while the likelihood ratio was statistically significant (0.001). The overall model prediction was 83.3%. However, the correlation of outcome with any of the variables, including mean LAmB dose per kilogram (82.2 ± 13.02 mg/kg), was statistically not significant.

CONCLUSION

Many patient-related factors (such as age, comorbidities, extent of the disease, and side effects from LAmB therapy), which vary on a case-to-case basis, contribute to the outcome in a mucormycosis patient. The optimum dose of LAmB for improved outcome still requires individualization guided by experience, till well-designed studies address the question.

Isavuconazole and Liposomal Amphotericin B as Successful Combination Therapy of Refractory Invasive Candidiasis in a Liver Transplant Recipient: A Case Report and Literature Review

Invasive fungal infections in liver transplant recipients are associated with elevated morbidity and mortality and pose a challenge to the treating physicians. Despite of lacking clinical data, the use of antifungal combination therapy is often considered to improve response rates in an immunocompromised patient population. We herein report a case of refractory invasive candidiasis in a liver transplant recipient treated successfully with a combination of isavuconazole und high-dose liposomal amphotericin B. The antimycotic combination treatment was able to clear a bloodstream infection with C. glabrata and led to regression of bilomas among tolerable side effects. The use of the above-mentioned antifungal combination therapy in a liver transplant recipient has not been reported previously. This case highlights the efficacy and safety of antifungal combination therapy in immunocompromised patients with refractory invasive candidiasis.

Evaluation of renal effects of liposomal amphotericin B in children with malignancies with KDIGO and RIFLE criteria

BACKGROUND

Amphotericin B is a broad-spectrum antifungal agent and is the backbone of the treatment for medically important opportunistic fungal pathogens in children. This study aimed to compare the nephrotoxicity associated with L-AmB in children with acute lymphoblastic leukemia and acute myeloid leukemia.

MATERIALS AND METHODS

A total of 112 pediatric acute lymphoblastic leukemia or acute myeloid leukemia patients who received treatment with L-AmB (Ambisome®) at the University of Health Sciences Dr Behcet Uz Children's Hospital over 7 years were included. The incidence of hypokalemia, decreased estimated glomerular filtration rate and presence of acute kidney injury was recorded.

RESULTS

The average L-AmB treatment duration was 17.1±15.0 days. Five patients (4.4%) of the patients had grade I acute renal injury according to KDIGO criteria and 16 patients (14.2%) had increased risk for kidney injury according to RIFLE criteria. There were no patients with eGFR decrease above 50% and no renal injury and failure were observed during L-AmB treatment. The rate of patients with hypokalemia in the pre-treatment was 17.9% and the post-L-AmB group was 50.0%. The rate of hypokalemia was higher in the post-treatment group (P=0.0015). Among the 112 patients, only two patients (1.7%) required cessation of L-AmB treatment due to resistant hypokalemia despite supplementation.

CONCLUSIONS

Hypokalemia was more common compared to glomerulotoxicity and acute renal injury (according to KDIGO and RIFLE criteria) in pediatric leukemia patients treated with L-AmB. Hypokalemia developed in nearly half of the patients and the study shows the need for randomized controlled trials and strategies for hypokalemia associated with L-AmB treatment.

Disseminated Fusarium bloodstream infection in a child with acute myeloid leukemia: A case report

BACKGROUND

Disseminated Fusarium is rare in healthy children. Children with hematological tumors may have secondary fungal infections, including Fusarium infections, which are due to tumor bone marrow infiltration or prolonged bone marrow suppression after chemotherapy. Because of the lack of typical clinical manifestations and effective antifungal drugs, early diagnosis and treatment of the disease are difficult, and the prognosis is poor.

CASE SUMMARY

The patient in this case was a 13-year-old female child with rash and fever as the first symptoms. She had the characteristics of the four stages of skin that are typical of Fusarium infection. She was diagnosed with disseminated Fusarium infection through skin biopsy and blood culture and diagnosed with Fusarium solani infection based on the morphological characteristics of the blood culture. After treatment with liposome amphotericin B combined with voriconazole, the child recovered.

CONCLUSION

This case highlights that for children with secondary agranulocytosis after receiving chemotherapy for hematological malignancies, once typical abnormal skin damage is found, the possibility of Fusarium infection should be considered, and voriconazole alone or in combination with polyenes may be the most effective anti-Fusarium drugs. Amphotericin B, the traditional drug of disseminated Fusarium disease, has a high mortality rate, and it is not recommended to use it alone. Adequate neutrophil counts are essential for the treatment of disseminated Fusarium bloodstream infection.

[Individualized antifungal therapy in critically ill patients with invasive fungal infection]

Invasive candidiasis (IC) is the most common invasive fungal infection (IFI) affecting critically ill patients, followed by invasive pulmonary aspergillosis (IPA). International guidelines provide different recommendations for a first-line antifungal therapy and, in most of them, echinocandins are considered the first-line treatment for IC, and triazoles are so for the treatment of IPA. However, liposomal amphotericinB (L-AmB) is still considered a second-line therapy for both clinical entities. Although in the last decade the management of IFI has improved, several controversies persist. The antifungal drugs currently available may have a suboptimal activity, or be wrongly used in certain IFI involving critically ill patients. The aim of this review is to analyze when to provide individualized antifungal therapy to critically ill patients suffering from IFI, emphasizing the role of L-AmB. Drug-drug interactions, the clinical status, infectious foci (peritoneal candidiasis is discussed), the fungal species involved, and the need of monitoring the concentration of the antifungal drug in the patient are considered.

Association between potassium supplementation and the occurrence of acute kidney injury in patients with hypokalemia administered liposomal amphotericin B: a nationwide observational study

Background

Hypokalemia and acute kidney injury (AKI) occur in patients administered liposomal amphotericin B (L-AMB), a wide-spectrum anti-fungicidal drug. However, the association between potassium supplementation and the occurrence of AKI in patients with hypokalemia who were administered L-AMB is not well understood.

Methods

Using nationwide claims data and laboratory data, the occurrence of AKI during L-AMB treatment was retrospectively compared between patients with hypokalemia who were or were not supplemented with potassium and between those adequately or inadequately supplemented with potassium (serum potassium levels corrected to ≥3.5 mEq/L or remained < 3.5 mEq/L, respectively) before or after L-AMB treatment initiation.

Results

We identified 118 patients who developed hypokalemia before L-AMB treatment initiation (43 received potassium supplementation [25 adequate and 18 inadequate supplementation] and 75 did not receive potassium supplementation), and 117 patients who developed hypokalemia after L-AMB initiation (79 received potassium supplementation [including 23 adequate and 15 inadequate supplementation] and 38 did not receive potassium supplementation). The occurrence of any stage of AKI was similar between patients with hypokalemia, regardless of potassium supplementation (i.e., before L-AMB treatment initiation [supplementation, 51%; non-supplementation, 45%; P = 0.570] or after L-AMB initiation [supplementation, 28%; non-supplementation, 32%; P = 0.671]). After adjusting for confounding factors, we found that the occurrence of any stage of AKI was not associated with potassium supplementation before L-AMB initiation (odds ratio [OR]: 1.291, 95% confidence interval [CI]: 0.584–2.852, P = 0.528) or after L-AMB initiation (OR: 0.954, 95% CI: 0.400–2.275, P = 0.915). The occurrence of any stage of AKI tended to decline in patients with hypokalemia who were adequately supplemented with potassium (44%) before, but not after, L-AMB initiation relative to that in patients inadequately supplemented with potassium (61%), however this result was not significant (P = 0.358).

Conclusion

Potassium supplementation was not associated with any stage of AKI in patients with hypokalemia who were administered L-AMB.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02450-7.

Efficacy of early administration of liposomal amphotericin B in patients with septic shock: A nationwide observational study

INTRODUCTION

Liposomal amphotericin B (L-AMB), a broad spectrum anti-fungicidal drug, is often administered to treat invasive fungal infections (IFIs). However, the most suitable time to initiate treatment in septic shock patients with IFI is unknown.

METHODS

Patients with septic shock treated with L-AMB were identified from the Japanese Diagnosis Procedure Combination national database and were stratified according to L-AMB treatment initiation either at septic shock onset (early L-AMB group) or after the onset (delayed L-AMB group) to determine their survival rates following septic shock onset and the shock cessation period.

RESULTS

We identified 141 patients administered L-AMB on the day of or after septic shock onset: 60 patients received early treatment, whereas 81 patients received delayed treatment. Survival rates after septic shock onset were higher in the early L-AMB group than in the delayed L-AMB group (4 weeks: 68.4% vs 57.9%, P = 0.197; 6 weeks: 62.2% vs 44.5%, P = 0.061; 12 weeks: 43.4% vs 35.0%, P = 0.168, respectively). The septic shock cessation period was shorter in the early L-AMB group than in the delayed L-AMB group (7.0 ± 7.0 days vs 16.5 ± 15.4 days, P < 0.001), with a significant difference confirmed after adjusting for confounding factors with propensity score matching (7.1 ± 7.2 days vs 16.7 ± 14.0 days, P = 0.001).

CONCLUSION

Early L-AMB administration at septic shock onset may be associated with early shock cessation.

[AmBisome, three challenges: Candida auris infection, central nervous system infection, and biofilm-associated infection]

The treatment of invasive fungal infections remains a challenge, both for the diagnosis and for the need of providing the appropriate antifungal therapy. Candida auris is a pathogenic yeast that is responsible for hospital outbreaks, especially in intensive care units; it is characterized by a high resistance to the antifungal agents and can become multidrug-resistant. At present, the recommended antifungal agents for the invasive infections with this pathogen are echinocandins, always after carrying out an antifungal susceptibility testing. In case of no clinical response or persistent candidemia, the addition of liposomal amphotericin B or isavuconazole may be considered. Both fungal infection of the central nervous system and that associated with biomedical devices remain rare entities affecting mainly immunocompromised patients. However, an increase in their incidence in recent years, along with high morbidity and mortality, has been shown. The treatment of these infections is conditioned by the limited knowledge of the pharmacokinetic properties of antifungals. A better understanding of the pharmacokinetic and pharmacodynamic parameters of the different antifungals is essential to determine the efficacy of the antifungal agents in the treatment of these infections.

Multiple Intravitreal Liposomal Amphotericin B for a Case of Candida glabrata Endophthalmitis

We report a case of Candida glabrata endophthalmitis which was effectively treated by intravitreal liposomal amphotericin B (L-AMB) injection. A 72-year-old man was referred to our department for positive blood culture of Candida glabrata. First ophthalmologic examination revealed a chorioretinal lesion in left eye, and the patient was diagnosed as possible candida chorioretinitis. Despite systemic antifungal therapy, his chorioretinal lesion increased in both eyes and complicated by vitritis. Intravitreal administration of L-AMB was introduced for probable candida endophthalmitis. Finally, improvement of vitritis and regression of chorioretinal lesions were obtained by total of 9 times intravitreal injection. Our case suggests the safety and efficacy of intravitreal L-AMB injection for Candida glabrata endophthalmitis.

[Liposomal amphotericin B: Clinical pharmacology, pharmacokinetics and pharmacodynamics]

Liposomal amphotericin B is a lipid formulation of the antifungal drug amphotericin B with some distinguishing characteristics in its pharmacological behavior that entail some clinical differences of great interest. The significant improvement in the systemic and renal tolerability is one of them. This fact is related to the great stability of the liposome, promoted by its negative charge, the presence of cholesterol and the remarkable thermo-stability of the remaining lipids that compose it. In this situation, amphotericin B seems to be released from the liposome not spontaneously but when the liposome binds to the ergosterol in the fungal cell membrane. For this reason, there is almost no free amphotericin B in plasma or tissues, although it seems that its availability is greater when there is fungal infection. As a consequence, when the pharmacokinetic behavior is studied, the concentration and availability of liposomal amphotericin B are very high, and its volume of distribution is reduced in comparison with the other formulations.

Intraocular penetration of liposomal amphotericin B after intravenous injection in inflamed human eyes

PURPOSE

To determine the intraocular penetration of amphotericin B (AMPH-B) after an intravenously injection of liposomal amphotericin B (L-AMB) in inflamed human eyes.

METHODS

Seven eyes of 5 patients with fungal eye diseases (endophthalmitis in 6 eyes and keratitis in 1 eye) were treated with intravenous injections of 100-250 mg/day of L-AMB. Samples of blood, corneal button, aqueous humor, and vitreous humor were collected and assessed for AMPH-B.

RESULTS

The AMPH-B level in the cornea (604.0 μg/g) of the case with fungal keratitis exceeded the minimum inhibitory concentration. However, the levels in the aqueous and vitreous humors of the cases with fungal endophthalmitis were lower, e.g., 0.02 ± 0.01 μg/ml (0.09% of serum level) in the aqueous humor and 0.05 ± 0.08 μg/ml (0.17% of serum level) in the vitreous humor.

CONCLUSIONS

The AMPH-B levels administered intravenously were very low in the aqueous and vitreous humors. Our findings indicate that intravenous L-AMB can be considered only for patients with mild endogenous fungal endophthalmitis, e.g., isolated chorioretinitis without vitreous extensions.

Liposomal amphotericin B is more effective in polymorphic lesions of post kala-azar dermal leishmaniasis

BACKGROUND

Post kala-azar dermal leishmaniasis (PKDL) is thought to be the reservoir of infection for visceral leishmaniasis in South Asia. The development of strategies for the diagnosis and treatment of PKDL are important for the implementation of the visceral leishmaniasis elimination program.

AIMS

Liposomal amphotericin B (L-AMB) has been an overwhelming success in the treatment of visceral leishmaniasis. However, the empirical three-week regimen of L-AMB proposed for PKDL was shown to be inadequate, especially in the macular variant. This study aimed to delineate response of the different variants of PKDL to L-AMB.

METHODS

Skin biopsies were collected from PKDL cases at disease presentation and upon completion of treatment with L-AMB. Parasite DNA was detected by Internal Transcribed Spacer-1 PCR (ITS-1 PCR) and quantified by amplification of parasite kDNA. CD68 + macrophages were estimated in tissue sections by immunohistochemistry.

RESULTS

Treatment with L-AMB decreased the parasite load by 97% in polymorphic cases but only by 45% in macular cases. The median parasite load (89965 vs 5445 parasites/μg of genomic DNA) as well as infiltration by CD68+ cells before treatment was much greater in the polymorphic cases.

LIMITATIONS

Although monitoring of the parasite load for 12 months post-treatment would have been ideal, this was not possible owing to logistical issues as well as the invasive nature of biopsy collection procedure.

CONCLUSION

A dramatic decrease in the parasite burden was noted in patients with polymorphic lesions. Although patients with macular disease also had a decrease in parasite burden, this was not as marked as in the polymorphic cases. There was also a significantly greater infiltration of CD68 + macrophages in polymorphic PKDL before therapy.

Mixed and disseminated paracoccidioidomycosis after liver transplantation: Case report

Paracoccidioidomycosis (PCM) is a systemic granulomatous fungal infection rarely associated with solid organ transplantation. We report the second case of PCM in an adult after liver transplantation. A 47-year-old woman who had undergone liver transplantation was hospitalized for flu-like symptoms and multiple erythematous ulcerated skin papules. There was lymphadenopathy, pulmonary compromise, and quickly progression to septic shock. PCM was confirmed by skin biopsy and serologic tests, and a satisfactory response to amphotericin B was achieved.

Successful Treatment of Breakthrough Trichosporon asahii Fungemia by the Combination Therapy of Fluconazole and Liposomal Amphotericin B in a Patient with Follicular Lymphoma

Invasive trichosporonosis is a rare and lethal fungal infection that occurs in immunocompromised patients. Breakthrough trichosporonosis can occur in patients treated with echinocandins since Trichosporon spp. are resistant to these antifungal agents. We report a case of breakthrough Trichosporon asahii fungemia. A 62-year-old Japanese woman with relapsed follicular lymphoma was treated empirically with broad-spectrum antibiotics and micafungin due to an intermittent fever during reinduction chemotherapy. After four cycles of anti-cancer chemotherapy, she experienced a high neutropenic fever and T. asahii was subsequently detected from a blood culture. The patient was not given voriconazole due to the contraindication for use with carbamazepine, and she was successfully treated with fluconazole plus liposomal amphotericin B without any serious complications. The combined therapy of fluconazole and liposomal amphotericin B may therefore be useful in treating T. asahii fungemia, especially in patients receiving antiepileptic agents.

Invasive pulmonary aspergillosis caused by Aspergillus terreus diagnosed using virtual bronchoscopic navigation and endobronchial ultrasonography with guide sheath and successfully treated with liposomal amphotericin B

Invasive aspergillosis is a significant cause of mortality in patients with hematological malignancy. Early diagnosis of invasive pulmonary aspergillosis (IPA) by bronchoscopy is recommended but is often difficult to perform because of small lesion size and bleeding risk due to thrombocytopenia. A 71-year-old woman had received initial induction therapy for acute myeloid leukemia. On day 22 of chemotherapy, she had a high fever, and the chest computed tomography scan revealed a 20-mm-sized nodule with a halo sign. Bronchoscopy assisted by virtual bronchoscopic navigation (VBN) and endobronchial ultrasonography with a guide sheath (EBUS-GS) was performed, and Aspergillus terreus was identified from the culture of obtained specimens. A. terreus is often resistant to amphotericin B; thus, voriconazole is usually recommended for treatment. However, the obtained A. terreus isolate showed minimal inhibitory concentrations of 2 µg/mL for voriconazole and 0.5 µg/mL for amphotericin B. Therefore, the patient was successfully treated with liposomal amphotericin B. For patients suspected of having IPA, early diagnosis and drug susceptibility testing are very important. This case suggests that bronchoscopy using VBN and EBUS-GS is helpful for accurate diagnosis and successful treatment even if the lesion is small and the patient has a bleeding risk.

Liposomal amphotericin B-induced reversible ototoxicity in a patient with disseminated histoplasmosis

Amphotericin B (AmB) is a polyene antifungal agent used widely for systemic fungal infections. Infusion-related side effects, nephrotoxicity, and dyselectrolytemia are well-known adverse effects with the use of this drug. Liposomal preparation of AmB has less adverse events. However, ototoxicity due to AmB is scarcely mentioned in the literature. We report a case of disseminated histoplasmosis who was treated with liposomal amphotericin B (LAmB) and developed hearing loss during the treatment, which recovered after discontinuing the drug. This is a rare adverse effect of LAmB and reported only once from India, to the best of our knowledge.

The clinical usage of liposomal amphotericin B in patients receiving renal replacement therapy in Japan: a nationwide observational study

Background

Liposomal amphotericin B (L-AMB), a broad-spectrum antifungicidal drug, is often used to treat fungal infections. However, clinical evidence of its use in patients with renal dysfunction, especially those receiving renal replacement therapy (RRT), is limited. Therefore, we evaluated the usage and occurrence of adverse reactions during L-AMB therapy in patients undergoing RRT.

Methods

Using claims data and laboratory data, we retrospectively evaluated patients who were administered L-AMB. The presence of comorbidities, mortality rate, treatment with L-AMB and other anti-infective agents, and the incidence of adverse reactions were compared between patients receiving RRT, including continuous renal replacement therapy (CRRT) and maintenance hemodialysis (HD), and those that did not receive RRT.

Results

In total, 900 cases met the eligibility criteria: 24, 19, and 842 cases in the maintenance HD, CRRT, and non-RRT groups, respectively. Of the patients administered L-AMB, mortality at discharge was higher for those undergoing either CRRT (15/19; 79%) or maintenance HD (16/24; 67%) than for those not receiving RRT (353/842; 42%). After propensity score matching, the average daily and cumulative dose, treatment duration, and dosing interval for L-AMB were not significantly different between patients receiving and not receiving RRT. L-AMB was used as the first-line antifungal agent for patients undergoing CRRT in most cases (12/19; 63%). Although the number of subjects was limited, the incidence of adverse events did not markedly differ among the groups.

Conclusion

L-AMB may be used for patients undergoing maintenance HD or CRRT without any dosing, duration, or interval adjustments.

A real-world prospective observational study on the efficacy and safety of liposomal amphotericin B in 426 patients with persistent neutropenia and fever

INTRODUCTION

Invasive fungal diseases are crucial causes of morbidity and mortality among patients with febrile neutropenia (FN). Though liposomal amphotericin B (L-AMB) is one of the agents recommended for first-line empirical antifungal therapy in patients with FN, large-scale clinical studies have not been performed in Japan.

METHODS

An open-label prospective multi-center study was carried out to evaluate the safety and efficacy of L-AMB in Japanese patients with FN suspected of having fungal infection.

RESULTS

Of the 426 patients registered, safety and efficacy evaluations were conducted for 424 and 399, respectively. By clinical response criteria using 5 composite endpoints, the response rate was 46.6% (186/399). The response rate by age were 54.5% (child: 30/55), 47.5% (adult: 97/204), 42.1% (elderly: 59/140) respectively. Regarding the composite endpoints, resolution of fever was observed in 61.2% (244/399), no breakthrough fungal infection in 99.0% (395/399), survival for 7 days or longer after the completion of treatment in 83.7% (334/399), no discontinuation of treatment due to toxicity or lack of efficacy in 60.9% (243/399), and successful treatment of any baseline fungal infection in 10/18. Adverse drug reactions (ADRs) developed in 61.1% (259/424), and frequent ADRs were hypokalemia, kidney dysfunction, and liver dysfunction, as previously reported.

CONCLUSIONS

The safety and efficacy profile of L-AMB in Japanese patients with FN suspected of having fungal infection were elucidated for the first time, through the analysis of a large number of cases including pediatric patients under real-world clinical settings collected in this nationwide study.

Good's syndrome and recurrent leishmaniasis: A case report and review of literature

We report the case of a 56-year-old Caucasian male affected by thymoma and myasthenia gravis that developed recurrent visceral leishmaniasis 11 years after thymectomy. After treatment of each relapse with liposomal amphotericin B the PCR-Leishmania was negative and the patient showed clinical improvement. An immunologic work-up was performed showing lymphopenia with an important decrease in CD4+ T cells (52 cells/μ) and CD4/CD8 ratio (0.2). HIV test was negative. On the basis of previous thymoma and myasthenia gravis and on the basis of the immunological profile a diagnosis of Good's syndrome was made. Since IFNγ plays a main role in the control of Leishmania infection the production of IFNγ was evaluated. After mitogen stimulation of peripheral blood mononuclear cells the production of IFNγ was lower than normal. This is the second reported case of Good's syndrome with recurrent leishmaniasis and indicates that a definitive cure for leishmaniasis in patients with Good's syndrome is not possible. Immunologic work-up in our patient strongly suggests that relapses could be correlated with the low CD4+ T cell number and with the low IFNγ production. Immunotherapy with IFNγ or with compounds able to block the Th2 interleukin production could be a therapeutic option in these patients.

Aspergillus fumigatus cholangitis in a patient with cholangiocarcinoma: case report and review of the literature

Aspergillus spp. cholangitis is an uncommon presentation of invasive aspergillosis. Only few cases are described in the literature affecting severely immunocompromised patients or patients following biliary surgery. Especially, invasive aspergillosis in non-haematological patients is associated with high mortality rates, caused by atypical presentations, which is associated with a delay in diagnosis and therapy. We report a 72-year-old man with primary diagnosis of cholangiocarcinoma and stent implantation by endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression who developed severe cholangitis with invasive aspergillosis. The patient had no history of prior hospitalisation, no immunosuppressive therapy and no preceding biliary surgery. Furthermore, in this exceptional case of extrapulmonary aspergillosis, there were no signs of pulmonary involvement. From the literature review, only three cases of Aspergillus cholangitis could be identified. Clinical manifestations of invasive aspergillosis can be variable and classical risk factors such as immunosuppression are not mandatorily present. Clinical awareness of these rare cases is of vital importance for initiation of correct therapy.

Molecular diagnosis and therapy for cutaneous leishmaniasis of a returned traveler from Mexico

Leishmaniasis is prevalent in Southern Europe, the Middle East, India, Africa, and Central and South America. Cutaneous leishmaniasis may spontaneously heal over time without treatment; however, risk of visceral dissemination and the impact of cosmetic defect are important concerns. We report a Case of cutaneous leishmaniasis in a patient who ever traveled to Mexico before the onset of a deteriorating wound around the swollen left eyebrow. A diagnosis of infection with Leishmania mexicana was made based on histopathological examination and molecular identification. Systemic treatment with liposomal amphotericin B and ketoconazole were administered with gradual healing of the lesion. Also, this traveler case implicates that the spread of endemic parasitic diseases may be a concealed risk on the public health for Taiwan underlying globalization.

Combination antifungal therapy without craniotomy in an immunocompromised patient with rhino-orbito-cerebral mucormycosis: A case report

Background

Mucormycosis is an uncommon fungal infection caused by the members of the order Mucorales. In susceptible patients, mucormycosis can infect any tissue or organ, and without suitable treatment (i.e., debridement and antifungal therapy), this infection can be fatal. Our patient was a woman with lymphoma and cerebral mucormycosis who was treated with antifungals and without any neurosurgical debridement.

Case Presentation

Herein, we present the case of a 35-year-old woman with diagnosis of B-cell lymphoma and rhino-orbito-cerebral mucormycosis (ROCM). She was a candidate for enucleation of the left eye, orbital decompression, and sinocerebral debridement. Nevertheless, the patient refused eye enucleation and craniotomy. Finally, she was treated with a combination of antifungals and sinus debridement without eye enucleation and craniotomy.

Conclusion

debridement, along with a combination of liposomal amphotericin B (LAMB) and posaconazole, may be a suitable therapeutic option for patients with ROCM, who are not eligible candidates for extensive surgery or craniotomy.

Case of mucormycosis of mandible after self-extraction of teeth incidentally detected to have chronic granulomatous disease: Case report and literature review

Mucormycosis isolated to the mandible is a rare presentation occurring generally after dental procedures. The case we report presented with discharging sinuses over facial region with radiological appearance of isolated osteomyelitis of the mandible. The patient used to apply an addictive dental powder over his teeth leading to caries. Following this, he pulled out all his teeth, which probably led to his condition. Invasive sampling revealed mucormycosis. An extensive search for an underlying immunodeficiency revealed that the patient had chronic granulomatous disease (CGD). Despite a prolonged course of L-Amphotericin B, the patient continued to have intermittent pus discharge and surgical debridement and curettage was eventually required. The patient had a chronic course with minimal soft tissue involvement which initially did not raise the suspicion of mucormycosis. The main learning point is that an unusual invasive fungal infection in an otherwise healthy host can be the first symptom of an underlying primary immunodeficiency, like CGD. Invasive fungal infections in patients with CGD often have an indolent course.

•

Mucormycosis isolated to the mandible is a rare presentation, occurring generally after dental procedures.

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Self-extraction of teeth as in our patient can result in isolated mucormycosis of the mandible.

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Isolated mucormycosis of the mandible can be a presenting symptom of chronic granulomatous disease.

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Combination of medical and surgical treatment is usually needed in mandibular mucormycosis.

Clinical characteristics and prognoses of pulmonary mucormycosis in four children

IMPORTANCE

Pulmonary mucormycosis is life threatening and carries a poor prognosis. Identification of factors that improve prognosis is urgently necessary.

OBJECTIVE

To analyze the clinical features and outcomes of pulmonary mucormycosis in children.

METHODS

A retrospective analysis of clinical data of four cases with pulmonary mucormycosis was conducted in Beijing Children's Hospital from January 2017 to December 2018.

RESULTS

Underlying diseases were identified in all four cases (diabetes in three individuals and a hematological malignancy in one individual). The predominant clinical manifestations were fever, cough, chest pain and hemoptysis. Imaging features included consolidation or nodules with cavities. All four cases were treated with liposomal amphotericin B, one case underwent lobectomy, and three cases received a full course of posaconazole. All four cases were cured.

INTERPRETATION

Patients with pulmonary mucormycosis often have underlying diseases. Imaging features are relatively characteristic. Treatment with liposomal amphotericin B at an early stage and a sufficient course of posaconazole for maintenance significantly improves prognosis.

Rhino-Orbital-Cerebral Mucormycosis after Allogeneic Hematopoietic Stem Cell Transplantation and Isavuconazole Therapeutic Drug Monitoring during Intestinal Graft versus Host Disease

A diagnosis of rhino-orbital-cerebral mucormycosis was made in a 59-year-old man with a secondary acute myeloid leukemia a few days after hematopoietic stem cell transplantation. Prompt treatment with combined antifungal therapy (liposomal amphotericin B and isavuconazole) followed by a procedure of endoscopic sinus surgery resulted in the resolution of the infection. Therapeutic drug monitoring of isavuconazole was performed during the year of treatment showing an increment of plasma concentrations in correspondence with the improvement of intestinal GvHD, thus suggesting that in this or similar conditions TDM for isavuconazole can be of value. A literature review of cases of rhino-orbital-cerebral and rhino-cerebral mucormycosis in allogeneic hematopoietic stem cell transplant recipients was carried out.

Effect of serum concentration and concomitant drugs on vancomycin-induced acute kidney injury in haematologic patients: a single-centre retrospective study

PURPOSE

Appropriate use of vancomycin (VCM) is important in preventing acute kidney injury (AKI). Because of the high frequency of VCM use for febrile neutropenia and concomitant use of other nephrotoxic drugs, haematologic patients have a different nephrotoxic background compared with patients with other diseases. Therefore, it is unclear whether the risk factors of VCM-induced AKI identified in other patient groups are also applicable to haematologic patients. Herein, we performed a single-centre retrospective analysis to identify the factors associated with VCM-induced AKI in haematologic patients.

METHODS

We retrospectively analysed 150 haematologic patients to whom VCM was administered between April 2010 and March 2018 at Tokushima University Hospital. VCM-induced AKI was defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariate logistic regression analyses were performed to identify risk factors for VCM-induced AKI.

RESULTS

Seventeen patients had VCM-induced AKI. Multivariate analysis revealed that the risk factors of VCM-induced AKI were an initial VCM trough concentration of > 15 mg/L and concomitant use of tazobactam/piperacillin (TAZ/PIPC) and liposomal amphotericin B (L-AMB). Patients with an initial VCM trough concentration of < 10 mg/L showed significantly lower efficacy in febrile neutropenia. Interestingly, concomitant L-AMB use increased the incidence of VCM-induced AKI in a VCM concentration-dependent manner, whereas concomitant TAZ/PIPC increased the incidence in a VCM concentration-independent manner.

CONCLUSIONS

The optimal initial VCM trough concentration was 10-15 mg/L in haematologic patients, considering safety and effectiveness. There were differences in the effect of VCM-induced AKI between nephrotoxic drugs.

Cutaneous leishmaniasis in non-endemic countries: An emerging yet neglected problem

Cutaneous leishmaniasis (CL) is the most common leishmaniasis syndrome, yet a neglected disease in industrialized non-endemic countries, where it has become an emergent problem. The lack of clinical experience, evidence-based literature and availability of some treatments complicates its management. We report a CL case in a 30 year-old man returned from Brazil, with a cutaneous ulcerated lesion, where it was possible to isolate Leishmania braziliensis/guyanensis complex (subgenus Viannia). An initial course of treatment with miltefosine was attempted, but considering the lack of response, liposomal amphotericin B was used, with very good results. Our report highlights the obstacles faced in the diagnosis and treatment of New World CL in non-endemic countries and the need for more funding and research.

Case of endobronchial metastasis from breast cancer accompanied with Cunninghamella bertholletiae tracheobronchial mycetoma

Cunninghamella is a member of the class Zygomycetes. Cunninghamella species include ubiquitous filamentous fungi; infections caused by Cunninghamella species are less frequent but have higher mortality rates than infections caused by Mucorales group members such as Rhizopus and Mucor. Herein, we reported a rare fatal case of endobronchial metastasis from breast cancer accompanied with Cunninghamella bertholletiae tracheobronchial mycetoma. A 73-year-old female with a history of right-sided breast cancer who had undergone mastectomy 11 years previously and had no recurrence presented to our emergency department with a 1-week history of left-sided back pain. Chest X-ray revealed left lung atelectasis; bronchoscopy revealed an endobronchial mass lesion in the left main bronchus. Pathological examination revealed fungal mycetoma but malignant lesions were not detected. Endobronchial and lung mycetoma caused by Cunninghamella bertholletiae were initially diagnosed; liposomal amphotericin B was administered, but her condition deteriorated. Rigid endoscopy showed growth of hemorrhagic tissue occupying the left main bronchus just under the carina. Pathological examination of the shaved lesion revealed metastasis from breast cancer covered with abundant necrotic tissue. No mold was observed in the necrotic tissue; this was probably due to liposomal amphotericin B treatment. To our knowledge, this is the first case of endobronchial metastasis from breast cancer accompanied with Cunninghamella bertholletiae mycetoma. Distinguishing endobronchial metastases from breast cancer and atypical presentations of Cunninghamella endobronchial mycetomas can be very difficult. Repeated bronchoscopies maybe helpful in establishing an accurate diagnosis when clinical prognosis does not match the initial diagnosis.

Fungemia due to Fusarium solani under low-dose liposomal amphotericin B in a patient after cord blood transplantation

The introduction of the prophylactic use of antifungal drugs caused the increased occurrence of invasive fungal infections due to previously rare molds, such as fusariosis, after allogeneic hematopoietic stem cell transplantation. We herein report the case of a patient with diffuse large B-cell lymphoma who developed fungemia due to Fusarium solani during liposormal amphotericin B on day 25 after cord blood transplantation (CBT). Because Fusarium species might differ in virulence and drug susceptibility, the sequencing of the internal transcribed spacer region of the ribosomal RNA gene accurately identified Fusarium solani to be the cause of fungemia at the species level. This case highlights Fusarium solani as the cause of fungemia in a patient under liposormal amphotericin B treatment after CBT.

Treatment of cerebral mucormycosis with drug therapy alone: A case report

We report on an elderly male patient with headache and right-side weakness. Imaging studies revealed multiple space-occupying lesions in the parietal and occipital cerebral regions. Biopsy revealed broad aseptate ribbon-like structures branching at right angles, suggestive of mucormycosis. Improvement was observed after medical therapy with 20 weeks of liposomal amphotericin B (5 mg/kg/day) combined with posaconazole, followed by posaconazole (400 mg twice a day) alone for 1 month. The patient recovered without neurological deficits; however, multidrug-resistant bacteraemia and hospital-acquired pneumonia occurred, resulting in death. Nevertheless, our report shows that this lethal fungal infection can sometimes show favourable progress with drug therapy alone.

Acute invasive fungal rhinosinusitis: our 2 year experience and outcome analysis

PURPOSE

The incidence of Acute invasive fungal rhinosinusitis (AIFRS) is on the rise considering the multitude of comorbidities present in a single patient.The delay in suspecting the fungal etiology, presentation of the patient for an Otorhinolaryngology consult and lack of defined protocols affects outcome.This study looks in to the various aspects of treatment of AIFRS including sample collection, diagnosis and medicosurgical treatment. We propose a protocol for the management of these patients crafted from our outcome.

METHODS

Between September 2015-September 2017, 14 patients presented with AIFRS. Targeted samples were taken for Potassium hydroxide mount, histopathological studies and fungal culture. Management was initiated with antifungals and multi-approach surgical debridement.

RESULTS

Six of these patients had multiple comorbidities and most were uncontrolled diabetics. The average delay in presentation was 9 days. Potassium hydroxide mount was the screening test of choice. A minimum of two sittings of debridement was essential. In an average follow-up period of 15.12 months, all the patients are alive and disease free.

CONCLUSION

A high index of suspicion, awareness among medical fraternity and precise sample collection aids a firm diagnosis. Simultaneous initiation of surgical debridement and anti-fungals is fundamental.

[Successful treatment of pre-engraftment disseminated fusariosis with high-dose liposomal amphotericin B in a cord blood transplant recipient]

A 47-year-old man with acute myeloid leukemia and myelodysplastic-related changes relapsed after an allogenic bone marrow transplant and received a cord blood transplant as salvage therapy. The patient developed febrile neutropenia that was resistant to broad-spectrum antibiotics and multiple, painful, nodular skin lesions on his trunk and extremities before engraftment. A skin biopsy and blood culture found mold, and the subsequent microscopic examination, mass spectrometry, and DNA sequencing of the fungal colonies identified Fusarium solani. The patient's fever and skin lesions began to improve with the administration of liposomal amphotericin B at 5 mg/kg/day. Neutrophilic engraftment occurred on day 19. Stage 3 acute skin graft-versus-host disease was cured by the application of topical steroid. Unexpectedly, a change from liposomal amphotericin B to voriconazole on day 38 exacerbated the Fusarium infection. The Fusarium infection was finally cured by the administration of liposomal amphotericin B for a total of 19 weeks. Neutrophilic engraftment, an immediate definitive diagnosis, the sufficient and long-term administration of appropriate antifungal medication, and avoidance of the systemic administration of steroids might have contributed to the successful outcome of this patient.

An unusual case of gastrointestinal basidiobolomycosis mimicking colon cancer; literature and review

Gastrointestinal basidiobolomycosis (GIB), a rare fungal infection associated with high mortality, has been reported worldwide mainly from tropical and subtropical regions of Asia, USA, and Latin America. The clinical manifestations are highly diverse and non-specific depending on the underlying disease, but fever, abdominal pain, weight loss, diarrhea, constipation and chills have been observed. There are no prominent risk factors for GIB but climatic conditions and life style are related to this infection in arid and semi-arid regions. Therefore timely diagnosis and early treatment is a challenge. Herein, we present an unusual case of gastrointestinal basidiobolomycosis in a 54-year-old male, initially misdiagnosed as colon cancer. After follow-up, no evidence of relapse and the patient was successfully cured by liposomal amphotericin B. In addition, the differential diagnosis and histopathological findings are discussed with a review of the literature.