Sinonasal Oxalosis due to Fungal Rhinosinusitis: A Unique Case of a Destructive Pseudotumor

Oxalosis refers to the accumulation of calcium oxalate crystals in various organs and tissues, most commonly due to Aspergillus infection involving the lung or sinonasal tract. Both invasive and noninvasive forms of fungal rhinosinusitis can be associated with calcium oxalate crystal deposition. Here, we report a unique case of sinonasal oxalosis presenting as a destructive lesion in the absence of invasive fungal disease. Due to the clinical and pathologic significance of calcium oxalate crystals as seen in this patient, specimens from the sinonasal tract should be evaluated for the presence of these crystals, which may be a surrogate marker for fungal infection and may also independently cause tissue destruction.

Retrospective evaluation of voriconazole treatment in psittacines: 14 cases (2012-2023)

OBJECTIVE

To retrospectively evaluate the clinical use of voriconazole in psittacine patients for the treatment of suspected respiratory fungal infections.

ANIMALS

14 client-owned psittacine birds.

METHODS

Medical records were searched from 2012 to 2023 for voriconazole use in psittacines. Species, age, clinical signs, physical examination findings, CT reports, bloodwork results, treatment, and outcome were obtained from the records or client follow-up.

RESULTS

African grey parrots were the most prevalent species (8/14). Dyspnea (9/14) and abnormal respiratory auscultation (11/14) were the most common examination abnormalities. An initial CT was performed in all cases, and pneumonia (10/14) and air sac disease (9/14) were the most common findings, with 8 cases having both pulmonary and air sac disease. Voriconazole doses ranged from 10 to 21 mg/kg (median, 16 mg/kg), with most cases prescribed as every-12-hour frequency (12/14). Three of 14 (21%) cases died or were euthanized within 24 days of diagnosis. One case was euthanized at 311 days, and 6 cases were lost to follow-up. Four of 14 (29%) cases lived > 12 months from diagnosis. Two of these cases cleared clinical infection after receiving voriconazole at 17 to 18 mg/kg (q 12 h). No adverse effects attributable to voriconazole were reported.

CLINICAL RELEVANCE

Voriconazole can be safely used for the treatment of suspected fungal respiratory infection in psittacines. However, the prognosis for resolution is guarded, and prolonged treatment and repeated diagnostic imaging are necessary in many cases.

Enhancing the quality of fermented plant leaves: the role of metabolite signatures and associated fungi

Fungi play a pivotal role in fermentation processes, influencing the breakdown and transformation of metabolites. However, studies focusing on the effects of fungal-metabolite correlations on leaf fermentation quality enhancement are limited. This study investigated specific metabolites and fungi associated with high- and low-quality fermented plant leaves. Their changes were monitored over fermentation periods of 0, 8, 16, and 24 days. The results indicated that organoheterocyclic compounds, lipids, lipid-like molecules, organic nitrogen compounds, phenylpropanoids, and polyketides were predominant in high-quality samples. The fungi Saccharomyces (14.8%) and Thermoascus (4.6%) were predominantly found in these samples. These markers exhibited significant changes during the 24-day fermentation period. The critical influence of fungal community equilibrium was demonstrated by interspecies interactions (e.g., between Saccharomyces and Eurotium). A co-occurrence network analysis identified Saccharomyces as the primary contributor to high-quality samples. These markers collectively enhance the quality and sensory characteristics of the final product.

PTP1B phosphatase dampens iPSC-derived neutrophil motility and antimicrobial function

Neutrophils are rapidly recruited to sites of infection and are critical for pathogen clearance. Therapeutic use of primary neutrophils has been limited as they have a short lifespan and are not amenable to genetic manipulation. Human induced pluripotent stem cells (iPSCs) can provide a robust source of neutrophils for infusion and are genetically tractable. However, current work has indicated that dampened intracellular signaling limits iPSC-derived neutrophil (iNeutrophil) cellular activation and antimicrobial response. Here, we show that protein tyrosine phosphatase 1B (PTP1B) inhibits intracellular signaling and dampens iNeutrophil effector function. Deletion of the PTP1B phosphatase increased PI3K and ERK signaling and was associated with increased F-actin polymerization, cell migration and phagocytosis. In contrast, other effector functions like NETosis and ROS production were reduced. PTP1B-deficient neutrophils were more responsive to A. fumigatus and displayed rapid recruitment and control of hyphal growth. Accordingly, depletion of PTP1B increased production of inflammatory factors including the neutrophil chemokine IL-8. Taken together, these findings suggest that PTP1B limits iNeutrophil motility and antimicrobial function.

Restoring the Ocular Integrity of Perforated Corneal Ulcer Using Living Surgical Donor Tissues Derived From Keratoplasty in the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) caused an unprecedented crisis for corneal surgeons who were forced to strategize for an acute shortage of tissues. Here, we report the initial clinical outcomes of utilizing host corneal buttons derived from optical penetrating keratoplasties of pseudophakic bullous keratoplasty (PBK) patients. Two patients presented to our department with a perforated fungal corneal ulcer in one eye during the COVID-19 pandemic. One eye of each of the patients was operated on with non-vascularized host cut tissues preserved in glycerin. The tissues were secured using 10-0 nylon sutures. Good anatomical integrity was achieved in both eyes. An optical penetrating keratoplasty (PK) was done in both eyes after one year for visual rehabilitation, with a final visual acuity of 20/120 and 20/80, respectively, at six months. In conclusion, therapeutic PK using host tissues obtained from the recipients of optical PK is a safe and effective option to restore ocular integrity during a shortage of fresh or glycerol-preserved corneas. However, optical PK is required for the final visual rehabilitation.

A Rare Case of Fungal Osteomyelitis of the Distal Tibia in a Pediatric Patient

Staphylococcus aureus infection is the most common cause of osteomyelitis. Over 100,000 fungal species have been described; only 150 are pathogenic to humans. These opportunistic infections frequently enter the body due to a decrease in host defense or through an invasive gateway, such as a dental extraction or skin discontinuity due to trauma. Symptoms and radiological examination often mimic those of other etiologies, which can lead to substantial delays in treatment. Our case is a 13-year-old healthy boy with no history of immune incompetency who presented to us with complaints of pain and swelling over his left ankle and leg with an on-and-off history of fever for 15 days. Based on his history and examination, he is diagnosed as having sub-acute osteomyelitis of the distal tibia with septic arthritis. The bacterial culture has no growth; however, the potassium hydroxide mount came positive for fungal elements having hyphae and pseudohyphae, and the fungal culture came positive for Candida. Management of fungal infections is challenging as they have infrequent involvement in bones. Fungal osteomyelitis is considered a rare entity in the literature, and the current case is studied for the management and diagnosis of a rare variant of osteomyelitis in the pediatric population. The treatment guidelines vary based on the identified organism and the duration of treatment. Debridement of fungal osteomyelitis or septic arthritis includes removing sinus tracts, evaluation for squamous cell carcinoma, bony and soft-tissue debridement, and antibiotic or antifungal bead placement. The spectrum of osteomyelitis ranges from Staphylococcus aureus organisms to tumors; therefore, it is necessary to investigate every spectrum of the disease, and fungal infections should be considered differential even though they are a rare entity. Early diagnosis, surgical debridement, and proper antifungal treatment based on fungal species lead to better clinical outcomes and results.

High-dose amphotericin: yay or nay? A case series and literature review

Invasive fungal infections pose significant morbidity and mortality risks, particularly those caused by moulds. Available antifungal classes are limited by toxicities and are increasingly susceptible to resistance, particularly amongst challenging fungal pathogens. The purpose of this case series and literature review was to characterize the use of a high-dose lipid formulation of amphotericin B. A case series is presented including patients who received high-dose lipid formulation amphotericin B (≥7.5 mg/kg/day) between June 2012 and August 2021. Additionally, a systematic literature review was conducted by searching the PubMed database for English-language studies involving individuals who received high-dose amphotericin B therapy (≥7.5 mg/kg) using lipid formulations. Nine patients were included in the case series, receiving an average of 8.9 ± 1.3 mg/kg liposomal amphotericin B over a mean of 11.0 ± 10.8 days predominantly for mould infections including Mucorales, aspergillosis and Fusarium. The patients were primarily cared for in intensive care units, with varying treatment histories and outcomes. A total of 11 studies (n=260 patients) met inclusion criteria for the literature review. Responses to high-dose liposomal amphotericin B ranged from 8% to 100%, often showing favourable outcomes. High doses of liposomal amphotericin B were well tolerated both in the case series and in published literature, with serum creatinine changes being the most commonly reported adverse event. However, multi-patient studies continue to report less than favourable (range 8-62%) response rates. High-dose liposomal amphotericin B, either alone or in combination with other antifungal agents, might be a viable strategy for managing invasive fungal infections when few treatment choices exist. This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.

Treatment of onychomycosis in an era of antifungal resistance: Role for antifungal stewardship and topical antifungal agents

A growing body of literature has marked the emergence and spread of antifungal resistance among species of Trichophyton, the most prevalent cause of toenail and fingernail onychomycosis in the United States and Europe. We review published data on rates of oral antifungal resistance among Trichophyton species; causes of antifungal resistance and methods to counteract it; and in vitro data on the role of topical antifungals in the treatment of onychomycosis. Antifungal resistance among species of Trichophyton against terbinafine and itraconazole-the two most common oral treatments for onychomycosis and other superficial fungal infections caused by dermatophytes-has been detected around the globe. Fungal adaptations, patient characteristics (e.g., immunocompromised status; drug-drug interactions), and empirical diagnostic and treatment patterns may contribute to reduced antifungal efficacy and the development of antifungal resistance. Antifungal stewardship efforts aim to ensure proper antifungal use to limit antifungal resistance and improve clinical outcomes. In the treatment of onychomycosis, critical aspects of antifungal stewardship include proper identification of the fungal infection prior to initiation of treatment and improvements in physician and patient education. Topical ciclopirox, efinaconazole and tavaborole, delivered either alone or in combination with oral antifungals, have demonstrated efficacy in vitro against susceptible and/or resistant isolates of Trichophyton species, with low potential for development of antifungal resistance. Additional real-world long-term data are needed to monitor global rates of antifungal resistance and assess the efficacy of oral and topical antifungals, alone or in combination, in counteracting antifungal resistance in the treatment of onychomycosis.

Structural and time-resolved mechanistic investigations of protein hydrolysis by the acidic proline-specific endoprotease from Aspergillus niger

Proline-specific endoproteases have been successfully used in, for example, the in-situ degradation of gluten, the hydrolysis of bitter peptides, the reduction of haze during beer production, and the generation of peptides for mass spectroscopy and proteomics applications. Here we present the crystal structure of the extracellular proline-specific endoprotease from Aspergillus niger (AnPEP), a member of the S28 peptidase family with rarely observed true proline-specific endoprotease activity. Family S28 proteases have a conventional Ser-Asp-His catalytic triad, but their oxyanion-stabilizing hole shows a glutamic acid, an amino acid not previously observed in this role. Since these enzymes have an acidic pH optimum, the presence of a glutamic acid in the oxyanion hole may confine their activity to an acidic pH. Yet, considering the presence of the conventional catalytic triad, it is remarkable that the A. niger enzyme remains active down to pH 1.5. The determination of the primary cleavage site of cytochrome c along with molecular dynamics-assisted docking studies indicate that the active site pocket of AnPEP can accommodate a reverse turn of approximately 12 amino acids with proline at the S1 specificity pocket. Comparison with the structures of two S28-proline-specific exopeptidases reveals not only a more spacious active site cavity but also the absence of any putative binding sites for amino- and carboxyl-terminal residues as observed in the exopeptidases, explaining AnPEP's observed endoprotease activity.

Medical Device-Associated Healthcare Infections: Sterilization and the Potential of Novel Biological Approaches to Ensure Patient Safety

Healthcare-associated infections caused by multi-drug-resistant pathogens are increasing globally, and current antimicrobial options have limited efficacy against these robust species. The WHO details the critically important bacterial and fungal species that are often associated with medical device HAIs. The effective sterilization of medical devices plays a key role in preventing infectious disease morbidity and mortality. A lack of adherence to protocol and limitations associated with each sterilization modality, however, allows for the incidence of disease. Furthermore, issues relating to carcinogenic emissions from ethylene oxide gas (EtO) have motivated the EPA to propose limiting EtO use or seeking alternative sterilization methods for medical devices. The Food and Drug Administration supports the sterilization of healthcare products using low-temperature VH2O2 as an alternative to EtO. With advances in biomaterial and medical devices and the increasing use of combination products, current sterilization modalities are becoming limited. Novel approaches to disinfection and sterilization of medical devices, biomaterials, and therapeutics are warranted to safeguard public health. Bacteriophages, endolysins, and antimicrobial peptides are considered promising options for the prophylactic and meta-phylactic control of infectious diseases. This timely review discusses the application of these biologics as antimicrobial agents against critically important WHO pathogens, including ESKAPE bacterial species.

Phytochrome-Interacting Proteins

Phytochromes are photoreceptors of plants, fungi, slime molds bacteria and heterokonts. These biliproteins sense red and far-red light and undergo light-induced changes between the two spectral forms, Pr and Pfr. Photoconversion triggered by light induces conformational changes in the bilin chromophore around the ring C-D-connecting methine bridge and is followed by conformational changes in the protein. For plant phytochromes, multiple phytochrome interacting proteins that mediate signal transduction, nuclear translocation or protein degradation have been identified. Few interacting proteins are known as bacterial or fungal phytochromes. Here, we describe how the interacting partners were identified, what is known about the different interactions and in which context of signal transduction these interactions are to be seen. The three-dimensional arrangement of these interacting partners is not known. Using an artificial intelligence system-based modeling software, a few predicted and modulated examples of interactions of bacterial phytochromes with their interaction partners are interpreted.

Clinical Implementation of β-Tubulin Gene-Based Aspergillus Polymerase Chain Reaction for Enhanced Aspergillus Diagnosis in Patients with Hematologic Diseases: A Prospective Observational Study

The β-tubulin (benA) gene is a promising target for the identification of Aspergillus species. Assessment of the clinical implementation and performance of benA gene-based Aspergillus polymerase chain reaction (PCR) remains warranted. In this study, we assessed the analytical performance of the BenA probe PCR in comparison with the Aspergenius kit. We prospectively collected bronchoalveolar lavage (BAL) fluid via diagnostic bronchoscopy from adult patients with hematologic diseases. BenA gene-based multiplex real-time PCR and sequential melting temperature analysis were performed to detect the azole resistance of Aspergillus fumigatus. In total, 76 BAL fluids in 75 patients suspicious of invasive pulmonary aspergillosis (IPA) were collected. Before the application of PCR, the prevalence of proven and probable IPA was 32.9%. However, after implementing the benA gene-based PCR, 15.8% (12 out of 76) of potential IPA cases were reclassified as probable IPA. The analytical performance of the BenA probe PCR in BAL samples was comparable to that of the Aspergenius kit. The diagnostic performance was as follows: sensitivity, 52.0%; specificity, 64.7%; positive predictive value, 41.9%; negative predictive value, 73.3%; positive likelihood ratio, 1.473; and negative likelihood ratio, 0.741. Moreover, benA gene-based Aspergillus PCR discriminated all major sections of Aspergillus, including cryptic species such as Aspergillus tubingensis. Sequential melting temperature analysis successfully detected 2 isolates (15.4%) of A. fumigatus carrying resistant mutations. BenA gene-based Aspergillus PCR with melting temperature analysis enhances diagnostic accuracy and detects not only cryptic species but also resistant mutations of A. fumigatus. It shows promise for clinical applications in the diagnosis of IPA.

Efficacy of Terbinafine and Itraconazole Combination Therapy Versus Terbinafine or Itraconazole Monotherapy in the Management of Fungal Diseases: A Systematic Review and Meta-Analysis

Fungal infections constitute a common dermatological illness rampant in underdeveloped countries. Combination drug therapy is becoming increasingly well-established owing to drug resistance because of monotherapy. Different studies have been conducted previously to compare the medical regimens for the treatment of fungal infections. However, there is insufficient research on the difference in cure rates and recurrence rates with each regimen. To the best of our knowledge, this meta-analysis is the first to compare the effect of the most widely used oral antifungal medications and their combination usage. A meta-analysis of randomized controlled trials (RCTs) assesses the efficacy of terbinafine or itraconazole monotherapy versus combination therapy in fungal diseases. We queried PubMed and Cochrane Central from their inception to April 2022 for published studies, RCTs, and observational studies without any language restriction that compared itraconazole and terbinafine combination therapy with monotherapy in patients with fungal infections. The results from the studies were presented as risk ratios (RRs) with 95% confidence intervals (CIs) and were pooled using a random-effects model, and a p-value of ≤0.05 was considered significant for the analysis. Endpoints of interest included cure rates and recurrence rates. Cure rates were increased significantly for combination therapy compared to terbinafine monotherapy (RR=2.01 (1.37, 2.94); p=0.0003; I2=67%). On sensitivity analysis, a significant association was observed between combination therapy and itraconazole monotherapy in terms of cure rates (RR=1.91 (1.41, 2.57); p<0.0001; I2=0%) and recurrence rates (RR=0.08 (0.02, 0.44); p=0.003; I2=0%). The findings of this meta-analysis suggest that itraconazole and terbinafine combination therapy has a better cure rate when compared to terbinafine monotherapy.

Approach to diagnostic evaluation and prevention of invasive fungal disease in patients prior to allogeneic hematopoietic stem cell transplant

In recent years, advancements in the treatment landscape for hematological malignancies, such as acute myeloid leukemia and acute lymphoblastic leukemia, have significantly improved disease prognosis and overall survival. However, the treatment landscape is changing and the emergence of targeted oral therapies and immune-based treatments has brought forth new challenges in evaluating and preventing invasive fungal diseases (IFDs). IFD disproportionately affects immunocompromised hosts, particularly those undergoing therapy for acute leukemia and allogeneic hematopoietic stem cell transplant. This review aims to provide a comprehensive overview of the pretransplant workup, identification, and prevention of IFD in patients with hematological malignancy. The pretransplant period offers a critical window to assess each patient's risk factors and implement appropriate prophylactic measures. Risk assessment includes evaluation of disease, host, prior treatments, and environmental factors, allowing a dynamic evaluation that considers disease progression and treatment course. Diagnostic screening, involving various biomarkers and radiological modalities, plays a crucial role in early detection of IFD. Antifungal prophylaxis choice is based on available evidence as well as individual risk assessment, potential for drug-drug interactions, toxicity, and patient adherence. Therapeutic drug monitoring ensures effective antifungal stewardship and optimal treatment. Patient education and counselling are vital in minimizing environmental exposures to fungal pathogens and promoting medication adherence. A well-structured and individualized approach, encompassing risk assessment, prophylaxis, surveillance, and patient education, is essential for effectively preventing IFD in hematological malignancies, ultimately leading to improved patient outcomes and overall survival.

An Uncommon Case of Fungal Rhinosinusitis Caused by the Mold Exserohilum rostratum in a Patient with Relapsed Acute Myeloid Leukemia: Case Report and Review of the Literature

Invasive fungal infections remain a devastating and potentially deadly complication in the setting of immunocompromised patients, such as in the setting of cancer, transplants, and other immune deficiencies. Infection with dematiaceous molds remains a less common but clear and present etiology. We present here a patient with relapsed acute myeloid leukemia who was neutropenic for a prolonged period. Symptoms worsened during the hospital course, including left-sided sinus swelling, which was also noted on imaging. ENT performed a bedside endoscopy and biopsied an eschar forming in the left nasal cavity. This was ultimately found to be acute invasive rhinosinusitis due to infection with the mold Exserohilum rostratum The patient was started on Posaconazole and Amphotericin B. He eventually also underwent surgical debridement. Infections with this organism are very uncommon, as noted in our literature search. In the diagnostic methods employed in this case, we utilized pathology, culture and microscopy, as well as mass spectrometry which was used to confirm the diagnosis.

Patterns of Common Dermatological Conditions among Children and Adolescents in Pakistan

Background and Objectives: Dermatological disorders are highly prevalent among children in Pakistan. The present cross-sectional study aims to identify the spectrum of dermatological conditions among children and adolescents in Pakistan. Materials and Methods: A total of 582 patients (50.9% males; 49.1% females) were included in the study based on their age (5.7 ± 4.1 years), dermatological condition, and epidemiology. The youngest patient was aged ten days, whereas the eldest was seventeen. Age criteria were further stratified into three categories: infants and toddlers (≤5 years), children (≥5 to <12 years), and adolescents (≥12 to <18 years). Amongst them, the majority was from Punjab (81.6%), while the other regions included were Azad Jammu and Kashmir (14.4%), Islamabad (3.3%), and Khyber Pakhtunkhwa (0.7%). Results: Scabies was the highest reported skin condition with 281 (45.55%) patients, followed by 114 (19.6%) with eczema, 60 (10.3%) with dermatitis, 33 (5.7%) with tinea capitis, 17 (2.9%) with tinea corporis, 16 (2.7%) with impetigo, and 15 (2.6%) with folliculitis. Other conditions include urticaria, burns, infections, pediculosis, tinea inguinalis, tinea faciei, nappy rashes, alopecia, warts, tinea incognito, tinea cruris, and acne vulgaris. The chi-squared test showed a high prevalence of tinea corporis and acne among adolescents (12-17 years), whereas eczema, dermatitis, and impetigo were more prevalent among infants and toddlers. Conclusions: Pets or livestock and poor hygiene were found to be highly reported risk factors for many dermatological conditions like scabies and fungal infections. Dermatological conditions are common in younger individuals, but unfortunately, many children do not receive the desired medical assistance.

Secondary and Co-Infections in Hospitalized COVID-19 Patients: A Multicenter Cross-Sectional Study in Malaysia

Bacterial and fungal secondary and co-infections are commonly identified with viral respiratory infections. This study was undertaken to determine the incidence and factors associated with bacterial and fungal infections in patients with COVID-19 as well as antibiotics prescription patterns within the first and second waves of the outbreak in Malaysia. Clinical records of 3532 COVID-19 patients admitted to hospitals in Malaysia between 4 February and 4 August 2020 were analyzed. Co-morbidities, clinical features, investigations, treatment, and complications were captured using the REDCap database. Culture and sensitivity test results were retrieved from the WHONET database. Univariate and multivariate regression analyses were used to identify associated determinants. A total of 161 types of bacterial and fungal infections were found in 81 patients, i.e., 2.3%. The most common bacterial cultures were Gram-negative, i.e., Pseudomonas aeruginosa (15.3%) and Klebsiella pneumoniae (13.9%). The most common fungal isolate was Candida albicans (41.2%). Augmentin, ceftriaxone, tazocin, meropenem, and azithromycin were the five most frequently prescribed antibiotics. The latter four were classified under the "Watch" category in the WHO AwaRe list. Our data showed that bacterial and fungal secondary and co-infections were frequently found in severely ill COVID-19 patients and were associated with a higher mortality rate.

Shared and unique antibody and B cell profiles in HIV-positive and HIV-negative individuals with cryptococcal meningoencephalitis

Host non-T cell markers to aid in the diagnosis of cryptococcal meningoencephalitis (CM) have not been identified. In this case-control study, we characterized antibody and B cell profiles in HIV-negative and HIV-positive Vietnamese individuals of the Kinh ethnicity recently diagnosed with CM and controls. The study included 60 HIV-negative with no known immunocompromising condition and 60 HIV-positive individuals, with 30 CM cases and 30 controls in each group. Participants were matched by age, sex, HIV serostatus, and CD4 count in the HIV-positive group. Plasma immunoglobulin (Ig) levels, including IgG1, IgG2, IgM, and IgA, Cryptococcus spp. glucuronoxylomannan (GXM)- and laminarin (branched ${\rm{\beta }}$-[1-3]-glucan)-binding IgG, IgM, IgA levels, and peripheral blood B cell subsets were measured. Logistic regression, principal component, and mediation analyses were conducted to assess associations between antibody, B cell levels, and CM. The results showed that GXM-IgG levels were higher and IgG1 and IgG2 were lower in CM cases than controls, regardless of HIV status. In HIV-negative individuals, IgG2 mediated an inverse association between CD19+CD27+CD43+CD5- (B-1b-like) cells and CM. In HIV-positive individuals, lower levels of IgA, laminarin-IgA, and CD19+CD27+IgM+IgD- (IgM+ memory B) cells were each associated with CM. The shared and distinct antibody and B cell profiles identified in HIV-negative and HIV-positive CM cases may inform the identification of non-T-cell markers of CM risk or unsuspected disease, particularly in HIV-negative individuals.

Hypoalbuminemia is a risk factor for invasive fungal infections and poor outcomes in infected kidney transplant recipients

INTRODUCTION

Invasive fungal infections (IFI), are estimated to occur in 2%-14% of kidney transplant recipients (KTRs) in the current era of immune suppression and are associated with high mortality rates. We hypothesized that hypoalbuminemia in KTRs is a risk factor for IFI and would be associated with poor outcomes.

METHODS

In this study, using data from a prospective cohort registry, we describe the frequency of IFI due to Blastomycosis, Coccidioidomycosis, Histoplasmosis, Aspergillosis, and Cryptococcus in KTRs with serum albumin levels measured 3-6 months before diagnosis. Controls were selected based on incidence density sampling. KTRs were divided into three groups based on the pre-IFI serum albumin level: normal (≥4 g/dL), mild (3-4 g/dL), or severe (<3 g/dL) hypoalbuminemia. Outcomes of interest were uncensored graft failure after IFI and overall mortality.

RESULTS

A total of 113 KTRs with IFI were compared with 348 controls. The incidence rate of IFI among individuals with normal, mild, and severe hypoalbuminemia was 3.6, 8.7, and 29.3 per 100 person-years, respectively. After adjustment for multiple variables, the trend for risk of uncensored graft failure following IFI was greater in KTRS with mild (HR = 2.1; 95% CI, .75-6.1) and severe (HR = 4.47; 95% CI, 1.56-12.8) hypoalbuminemia (P-trend < .001) compared to those with normal serum albumin. Similarly, mortality was higher in severe hypoalbuminemia (HR = 1.9; 95% CI, .67-5.6) compared to normal serum albumin (P-trend < .001).

CONCLUSION

Hypoalbuminemia precedes the diagnosis of IFI in KTRs, and is associated with poor outcomes following IFI. Hypoalbuminemia may be a useful predictor of IFI in KTRs and could be incorporated into screening algorithms.

Immune Adjuvant Therapy With Interleukin-7 in a Lymphopenic Patient With Aplastic Anemia and Mucormycosis

BACKGROUND

We report the case of a patient with aplastic anemia and pancytopenia on immune-suppressive therapy who developed invasive pulmonary infection with mucormycosis and was treated with immune adjuvant therapy.

CASE SUMMARY

Given the patient's profound lymphopenia and progressive invasive mucor despite dual antifungal drug therapy, interleukin (IL)-7, a cytokine that induces lymphocyte activation and proliferation, was instituted and resulted in normalization of absolute lymphocyte counts and was temporally associated with clearance of fungal pathogens and resolution of clinical symptoms.

CONCLUSION

Patients with life-threatening fungal infections are frequently immune suppressed and immune adjuvant therapies should be considered in patients who are not responding to antifungal drugs and source control. Well-designed, double-blind, placebo-controlled trials are needed to advance the field. Although a number of immune adjuvants may be beneficial in fungal sepsis, IL-7 is a particularly attractive immune adjuvant because of its broad immunologic effects on key immunologic pathways that mediate enhanced antifungal immune system activity.

The Outcomes of Hip and Knee Fungal Periprosthetic Joint Infections: A Retrospective Cohort Study

BACKGROUND

Fungal infections are a rare cause of periprosthetic joint infection (PJI), identified in 1% of all of these cases. Outcomes are not well-established due to small cohort sizes in the published literature. The aims of this study were to establish the patient demographics and infection-free survival of patients presenting to 2 high-volume revision arthroplasty centers who had fungal infection of either a hip or knee arthroplasty. We sought to identify risk factors for poor outcomes.

METHODS

A retrospective analysis was performed of patients at 2 high-volume revision arthroplasty centers who had confirmed fungal PJI of the total hip arthroplasty (THA) and total knee arthroplasty (TKA). Consecutive patients treated between 2010 and 2019 were included. Patient outcomes were classified as infection eradication or persistence. A total of 67 patients who had 69 fungal PJI cases were identified. There were 47 cases involving the knee and 22 of the hip. Mean age at presentation was 68 years (THA mean 67, range 46 to 86) (TKA mean 69, range, 45 to 88). A history of sinus or open wound was present in 60 cases (89%) (THA 21 cases, TKA 39 cases). The median number of operations prior to the procedure at which fungal PJI was identified was 4 (range, 0 to 9), THA 5 (range, 3 to 9), and TKA 3 (range, 0 to 9).

RESULTS

At a mean follow-up 34 months (range, 2 to 121), remission rates were 11 of 24 (45%) and 22 of 45 (49%) for hip and knee, respectively. There were 7 TKA (16%) and 1 THA cases (4%) that failed treatment resulting in amputations. During the study period, 7 THA and 6 TKA patients had died. Two deaths were directly attributable to PJI. Patient outcome was not associated with the number of prior procedures, patient comorbidities, or organisms.

CONCLUSION

Eradication of fungal PJI is achieved in less than half of patients, and outcomes are comparable for TKA and THA. The majority of patients who have fungal PJI present with an open wound or sinus. No factors were identified that increase the risk of persistent infection. Patients who have fungal PJI should be informed of the poor outcomes.

Exogenous cryptococcal endophthalmitis in an immunocompetent patient

We describe a case of exogenous cryptococcal endophthalmitis without central nervous system (CNS) involvement or systemic infection in an immunocompetent patient. An 82-year-old male with hypertension, hyperlipidemia, type 2 diabetes mellitus, and primary open-angle glaucoma with a history of left eye trabeculectomy presented with 3 months of worsening left eye pain and redness. Vitreous cultures resulted as Cryptococcus, prompting treatment with intravitreal amphotericin and further investigation. Systemic workup was unrevealing for an endogenous source, CNS involvement, or immunocompromising conditions. He was treated with an aggressive regimen of systemic antifungals, leading to subjective improvements in clinical exam and in vision.

Fungal Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management

Fungal endocarditis accounts for 1% to 3% of all infective endocarditis cases, is associated with high morbidity and mortality (>70%), and presents numerous challenges during clinical care. Candida spp. are the most common causes of fungal endocarditis, implicated in over 50% of cases, followed by Aspergillus and Histoplasma spp. Important risk factors for fungal endocarditis include prosthetic valves, prior heart surgery, and injection drug use. The signs and symptoms of fungal endocarditis are nonspecific, and a high degree of clinical suspicion coupled with the judicious use of diagnostic tests is required for diagnosis. In addition to microbiological diagnostics (e.g., blood culture for Candida spp. or galactomannan testing and PCR for Aspergillus spp.), echocardiography remains critical for evaluation of potential infective endocarditis, although radionuclide imaging modalities such as 18F-fluorodeoxyglucose positron emission tomography/computed tomography are increasingly being used. A multimodal treatment approach is necessary: surgery is usually required and should be accompanied by long-term systemic antifungal therapy, such as echinocandin therapy for Candida endocarditis or voriconazole therapy for Aspergillus endocarditis.

Invasive Candidiasis in Adult Patients with COVID-19: Results of a Multicenter Study in St. Petersburg, Russia

We studied the risk factors, etiology, clinical manifestations, and treatment outcomes of COVID-19-associated invasive candidiasis (COVID-IC) in adult patients admitted to six medical facilities in St. Petersburg. (November 2020-December 2022). In this retrospective study, we included 72 patients with COVID-IC with a median age of 61 years (range 29-96), 51% of whom were women. The predisposing factors for COVID-IC were a central venous catheter (CVC) for more than 10 days (the odds ratio (OR) = 70 [15-309]), abdominal surgical treatment performed in the previous 2 weeks (OR = 8.8 [1.9-40.3]), bacteremia (OR = 10.6 [4.8-23.3]), pulmonary ventilation (OR = 12.9 [5.9-28.4]), and hemodialysis (OR = 11.5 [2.5-50.8]). The signs and symptoms of COVID-IC were non-specific: fever (59%), renal failure (33%), liver failure (23%), and cardiovascular failure (10%). Candida albicans (41%) predominated among the pathogens of the candidemia. The multidrug-resistant Candida species C. auris (23%) and C. glabrata (5%) were also identified. Empirical therapy was used in 21% of COVID-IC patients: azole-93%, echinocandin-7%. The majority of COVID-IC patients (79%) received, after laboratory confirmation of the diagnosis of IC, fluconazole (47%), voriconazole (25%), echinocandin (26%), and amphotericin B (2)%. The 30 days overall survival rate was 45%. The prognosis worsened concomitant bacteremia, hemodialysis, and long-term therapy by systemic glucocorticosteroids (SGCs), bronchial colonization with Candida spp. The survival prognosis was improved by the early change/replacement of CVC (within 24 h), the initiation of empirical therapy, and the use of echinocandin. Conclusions: We highlighted the risk factors that predispose COVID-19 patients to candidiasis and worsen the survival prognosis. Their individual effects in patients with COVID-19 must be well understood to prevent the development of opportunistic co-infections that drastically lower chances of survival.

Reduction in PLANT DEFENSIN 1 expression in Arabidopsis thaliana results in increased resistance to pathogens and zinc toxicity

Ectopic expression of defensins in plants correlates with their increased capacity to withstand abiotic and biotic stresses. This applies to Arabidopsis thaliana, where some of the seven members of the PLANT DEFENSIN 1 family (AtPDF1) are recognised to improve plant responses to necrotrophic pathogens and increase seedling tolerance to excess zinc (Zn). However, few studies have explored the effects of decreased endogenous defensin expression on these stress responses. Here, we carried out an extensive physiological and biochemical comparative characterization of (i) novel artificial microRNA (amiRNA) lines silenced for the five most similar AtPDF1s, and (ii) a double null mutant for the two most distant AtPDF1s. Silencing of five AtPDF1 genes was specifically associated with increased aboveground dry mass production in mature plants under excess Zn conditions, and with increased plant tolerance to different pathogens - a fungus, an oomycete and a bacterium, while the double mutant behaved similarly to the wild type. These unexpected results challenge the current paradigm describing the role of PDFs in plant stress responses. Additional roles of endogenous plant defensins are discussed, opening new perspectives for their functions.

Postoperative Aspergillus Endophthalmitis With Iris Granuloma: A Case Report

This report describes a rare case of a fungal iris granulomatous lesion in a 67-year-old female who underwent cataract surgery in the left eye and, one month later, developed culture-positive postoperative Aspergillus endophthalmitis. On initial presentation in the emergency room, slit-lamp examination of the left eye revealed subconjunctival hemorrhage, 360-degree subconjunctival hemorrhage, mild corneal edema with Descemet's folds, a deep anterior chamber with a fibrinous reaction causing pupillary membrane formation, and an in situ intraocular lens with no view of the fundus. A bright-scan (B-scan) ultrasound revealed mild vitreous opacities with a vitreal membrane, shallow choroidal detachment, and no significant retinal and choroid layer thickening. The patient was admitted into the anterior segment division for anterior chamber (AC) tap culture and AC washout for suspected retained cortical matter removal, intracameral antibiotics (vancomycin and ceftazidime), and IOL explantation in the left eye. The initial aqueous tap culture had no growth. Nine days later, repeat aqueous tap and pupillary membrane cultures were positive for Aspergillus spp. Intravitreal voriconazole was administered along with topical natamycin and amphotericin B eye drops. There was a resolution of the clinical picture, and three weeks later a rebound occurred, for which AC washout, pars plana vitrectomy (PPV), capsulectomy, and intravitreal vancomycin, ceftazidime, and voriconazole were given. A week later, the patient developed a fungal granuloma behind the iris, which was successfully managed with an AC washout, removal of the granuloma, and repeated intravitreal and intracameral voriconazole administration. The best-corrected visual acuity (BCVA) during the last visit was 20/80 in the affected eye, with a plan for a secondary IOL implant. Endophthalmitis is a rare but serious intraocular infection, with fungal endophthalmitis having a lower prevalence than bacterial endophthalmitis, which explains the lack of well-established guidelines for diagnosing and managing exogenous fungal endophthalmitis. This case highlights the rare presentation of post-cataract Aspergillus endophthalmitis with a fungal iris granuloma and demonstrates how the chronicity of this infection, along with surgical manipulation, may accelerate the seeding of these organisms into the anterior chamber structures.

Evaluation of the Clinical Course of Endogenous Endophthalmitis

Purpose: To evaluate the presentations, clinical course, treatments, and outcomes of endogenous endophthalmitis cases. Methods: Consecutive medical records from 2016 to 2021 of a county hospital and an academic, private hospital in Dallas, Texas were retrospectively reviewed. This study comprised 37 eyes of 31 patients with endogenous endophthalmitis. Collected data included demographic factors, identifiable risk factors, medical history, presenting symptoms, infectious data, complications, and best-corrected visual acuity (VA) throughout the clinical course. Results: Twenty-two eyes had bacterial endophthalmitis, 7 had fungal endophthalmitis, and 8 had infections that could not be classified. Of the bacterial cases, 5 eyes had panophthalmitis with associated cellulitis. The most common organisms were Staphylococcus aureus, Candida albicans, and Pseudomonas aeruginosa. The most common presenting symptoms were decreased vision (70%), eye redness (41%), and eye pain (38%). Among all cases, there was no significant difference in the presenting logMAR VA (1.86) before treatment and the most recent logMAR VA (1.75; P = .70) after treatment. However, fungal infections demonstrated better logMAR VA than bacterial infections 6 months after diagnosis (mean logMAR VA, 0.93 vs 2.54, respectively; P = .016) and at most recent follow-up (mean logMAR VA, 0.76 vs 2.3, respectively; P = .004). There was also a strong correlation between presenting VA and most recent VA (r2 = 0.81; P < .01). Conclusions: Visual outcomes of endogenous endophthalmitis cases were poor. Our study found 2 components to be predictive of final VA: (1) whether the infecting organism was bacterial or fungal and (2) a patient's presenting VA.

Histological Findings in Captive Madagascar Hissing Cockroaches (Gromphadorhina portentosa) and a Literature Review

Madagascar hissing cockroaches (MHC, Gromphadorhina portentosa) are members of the Blaberidae (giant cockroaches) family of the Insecta class. They are native to the African island of Madagascar where they live within leaf litter on the rainforest floor. Due to their large size, relative tameness, and general easy keeping, they have become popular in classrooms, zoological collections, museums, research laboratories, and as private exotic pets; however, descriptions of diseases of MHC in the literature are rare. The objective of this study is to describe and characterize postmortem histological findings in 18 captive MHC from a single zoological collection. In this retrospective study, 18 (4 females and 14 males) adult MHC necropsies were submitted to Northwest ZooPath between 2016 and 2020 for evaluation. The main organs with histological lesions were chitinous gut (foregut and/or hindgut; n = 17), tracheae (n = 15), fat body (n = 14), ventriculus (midgut) (n = 13), body wall (n = 12), Malpighian tubules (n = 12), and hemolymphatic sinuses (n = 12). All animals had inflammatory lesions affecting various organs. Inflammatory lesions typically consisted of aggregates of hemocytes with variable amounts of melanization and/or encapsulation. Bacterial, fungal, and parasitic infections were common and variably associated with hemocytic inflammation. Many of these organisms may represent symbiotic organisms of the MHC that cause opportunistic infections. This study contributes to the current knowledge of pathological findings and disease response of MHC and reviews diseases reported in multiple cockroach species.

Endogenous Endophthalmitis - A Major Review

Endogenous endophthalmitis (EE) is an uncommon but potentially devastating ocular infection involving the inner layers of the eye. The global incidence of EE is on the rise. Common ocular signs and symptoms associated with EE include conjunctival injection, ocular pain, and reduced visual acuity. On clinical examination, a history of prior or coexisting systemic infections, symptoms (e.g., fever, malaise), and localizing features may be noted. Clinical diagnosis is often challenging, resulting in critical delays that contribute to a poor prognosis. Blood cultures and ocular fluid samples can aid in conforming causative pathogen(s), after which empirical antibiotic therapy, both systemic and intravitreal, should be instated. The use of steroids to suppress inflammation remains controversial. Surgical options include pars plana vitrectomy. Overall prognosis varies depending on host and pathogen factors, and early diagnosis and initiation of appropriate treatment are crucial.

Expression of ERG11, ERG3, MDR1 and CDR1 genes in Candida tropicalis

INTRODUCTION

Drug resistance to azoles is a growing problem in the Candida genus.

OBJECTIVE

To analyze molecularly the genes responsible for fluconazole resistance in Candida tropicalis strains.

MATERIALS AND METHODS

Nineteen strains, with and without exposure to fluconazole, were selected for this study. The expression of MDR1, CDR1, ERG11, and ERG3 genes was analyzed in sensitive, dose-dependent sensitive, and resistant strains exposed to different concentrations of the antifungal drug.

RESULTS

MDR1, ERG11 and ERG3 genes were significantly overexpressed in the different sensitivity groups. CDR1 gene expression was not statistically significant among the studied groups. Seven of the eight fluconazole-resistant strains showed overexpression of one or more of the analyzed genes. In some dose-dependent sensitive strains, we found overexpression of CDR1, ERG11, and ERG3.

CONCLUSION

The frequency of overexpression of ERG11 and ERG3 genes indicates that they are related to resistance. However, the finding of dose-dependent resistant/sensitive strains without overexpression of these genes suggests that they are not exclusive to this phenomenon. More basic research is needed to study other potentially involved genes in the resistance mechanism to fluconazole.

First Report on Choanephora cucurbitarum Causing Choanephora Rot in Chenopodium Plants and Its Sensitivity to Fungicide

Choanephora rot of Chenopodium plants (CRC) was observed at the flowering stages in seven plantations of Shanxi Province, China. CRC had caused leaf, stem, and panicle neck rot of C. quinoa, panicle neck and stem rot of C. formosanum, and stem rot of C. album. Typical symptoms included water-soaked, rapid soft rotting, and abundant sporulation on the whole panicle necks, stems, and leaves. Based on morphological characteristics, phylogenetic analyses, and pathogenicity tests, the pathogens were identified as Choanephoraceae cucurbitarum. Sporangiola and sporangiospore of C. cucurbitarum germinated at 30 °C and were able to germinate by two h post-inoculation (hpi). The germination rates of sporangiola and sporangiospore significantly increased at 3 to 4 hpi, and the germination rates ranged from 91.53 to 97.67%. The temperature had a significant effect on the pathogenicity of C. cucurbitarum the optimum pathogenic temperatures for stems of C. quinoa, C. formosanum and C. album were 30 °C after one day post-inoculation. Choanephoraceae cucurbitarum could infect white and red quinoa panicle necks between 20 and 30 °C, and the average lesion lengths were 0.21 to 3.62 cm. Among the five tested fungicides (boscalid, dimethomorph, isopyrazam, propiconazole, and tebuconazole), isopyrazam showed higher sensitivity to sporangiola germination of C. cucurbitarum, with an EC50 value of 0.6550 μg/mL. Isopyrazam and tebuconazole strongly inhibited the sporangiospore germination of C. cucurbitarum, which showed EC50 values of 0.4406 and 0.3857 μg/mL. To our knowledge, the present study found for the first time that C. cucurbitarum is a pathogen causing panicle neck of C. formosanum and stem rot of C. formosanum and C. album, while CRC first appeared in the quinoa panicle necks, and gradually expanded to stems and leaves.

Low Molecular Weight and High Deacetylation Degree Chitosan Batch Alleviates Pathogenesis, Toxin Accumulation, and Fusarium Gene Regulation in Barley Leaf Pathosystem

Fusarium graminearum is a cosmopolitan fungal pathogen that destroys cereal production, in terms of loss of yield and grain contamination with mycotoxins, worldwide. Chitosan is a natural biopolymer abundant in the environment with proven antifungal properties that also acts as a plant immunity elicitor. Despite a number of articles, there is a lack of systematic comparison of antifungal activity of diverse batches of chitosan. The current study aimed to test the inhibitory effects of a collection of diverse chitosan samples on the growth and production of F. graminearum toxins, validated by changes in the Fusarium transcriptome. Experiments included testing antifungal activity of different chitosan samples, the application of the best performing one in vitro to investigate the impact on F. graminearum growth, followed by analyzing its effect on Fusarium toxins accumulation, and Fusarium transcriptomics in the barley leaf pathosystem. Confirmatory antifungal assays revealed that CS_10, a specific batch of chitosan, retarded Fusarium growth with an application concentration of 200 ppm, significantly reducing toxin synthesis and disease symptoms in Fusarium-inoculated barley leaves. RNA-Seq analysis of F. graminearum in barley leaf pathosystem exposed to CS_10 showed a list of differentially expressed genes involved in redox balance, cell respiration, nutrient transport, cell wall degradation enzymes, ergosterol biosynthesis, and trichothecenes production. The genes functioning in these essential pathways are discussed and assigned as critical checkpoints to control Fusarium infections. The results suggest some important molecular targets in F. graminearum that may be suitable in gene-specific targeting or transgene-free methods, such as spray-induced gene silencing during host-pathogen interactions.

Cryptococcal Meningitis in Young, Immunocompetent Patients: A Single-Center Retrospective Case Series and Review of the Literature

Background

Cryptococcal meningitis is an uncommon but serious infection with high mortality and morbidity. Classically described in immunocompromised patients, including those with solid organ transplants or HIV/AIDS, cryptococcosis has also been reported in young and otherwise healthy patients, albeit rarely.

Methods

We retrospectively searched for all cases of cryptococcal meningitis in young (≤50 years) and previously healthy patients with no known immunocompromising conditions from January 2015 to January 2022 at Indiana University Health (IU Health). Additionally, a PubMed literature review was performed with the keywords "cryptococcal meningitis" and "immunocompetent" from January 1988 to January 2022. Clinical courses, including outcomes and treatment regimens, were evaluated.

Results

We identified 4 local cases of cryptococcal meningitis in otherwise healthy patients age ≤50 years. Three cases were due to Cryptococcus neoformans, with 1 experiencing a postinfectious inflammatory response syndrome (PIIRS). The PubMed search identified 51 additional cases, with 32 (63%) being caused by Cryptococcus neoformans and 8 (17%) by Cryptococcus gattii. Of the 51 cases, only 2 resulted in death directly due to cryptococcosis. Fifteen (29%) had PIIRS, with steroid treatment documented in 11 of 15. Antifungal induction regimens and duration were varied but predominately consisted of amphotericin and flucytosine, with a mean induction duration of 5.0 weeks.

Conclusions

Cryptococcal meningitis in young, previously healthy patients is likely under-recognized. PIIRS (akin to immune reconstitution inflammatory syndrome observed in HIV/AIDS) with prolonged recovery should be of concern. Determining risk factors for cryptococcosis in these patients remains elusive.

Lecythophora Soft-Tissue Infection: Case Report and Treatment Considerations

Lecythophora hoffmannii is a saprophytic fungus commonly found in the environment. Able to be isolated from soil, it is frequently associated with the soft rot of wood. Although human infections are not common, they have been reported, and have ranged from keratitis and soft-tissue infection to deep osteomyelitis and endometritis. Here we report a case of soft-tissue infection with this pathogen along with successful treatment with standard-dose terbinafine when other agents were unavailable. The true prevalence of infections with this pathogen is unclear and further data are needed to determine optimal therapy.

Unusual Presentation of Disseminated Histoplasmosis in an Immunocompetent Host

Histoplasmosis, a fungal infection caused by the inhalation of Histoplasma capsulatum conidia spores, has been shown to cause disseminated disease in immunocompromised individuals. Disseminated histoplasmosis manifests as multi-system involvement including pulmonary and/or neurological disease. Imaging findings, such as pulmonary focal infiltrates, cavitary nodules, mediastinal, and hilar lymphadenopathy, are common. Here, we report a rare case of disseminated histoplasmosis in a 58-year-old immunocompetent male with no occupational exposure. This patient presented with primary adrenal insufficiency, and a subsequent CT-guided biopsy of the adrenal gland was performed and revealed numerous spores containing Histoplasma capsulatum. This patient also suffered from numerous pulmonary and neurological derangements, which are likely sequelae of the disseminated fungal infection. Ultimately, the patient succumbed to their illness and died. Preventing such outcomes relies on early detection and prompt management, which are crucial in treating disseminated histoplasmosis. Increased awareness of atypical presentations can enhance patient outcomes and alleviate the impact of this severe fungal infection. This case not only underscores the importance of considering disseminated histoplasmosis in an immunocompetent patient presenting with unexplained weight loss and adrenal insufficiency but also contributes to the limited literature on disseminated histoplasmosis in immunocompetent individuals.

Native-Valve Aspergillus Endocarditis: Case Report and Literature Review

Aspergillus endocarditis represents the second etiological cause of prosthetic endocarditis following Candida spp. On the other hand, native-valve endocarditis due to Aspergillus are anecdotally reported with increasing numbers in the last decade due to new diagnostic technologies such as polymerase chain reaction (PCR) on samples like valve tissue or entire blood. We performed a review of the literature presenting one case report observed at Pisa University Hospital. Seventy-four case reports have been included in a period between 1950-2022. Immunocompromised status (patients with solid tumor/oncohematological cancer or transplanted patients) was confirmed to be the main risk factor for this rare opportunistic infection with a high rate of metastatic infection (above all, central nervous system) and mortality. Diagnosis relies on serum galactomannan and culture with PCR on valve tissue or whole blood. Cardiac surgery was revealed to be a life-saving priority as well as appropriate antifungal therapy including b-liposomal amphotericin or new triazoles (isavuconazole). The endocarditis team, facing negative blood culture endocarditis affecting an immunocompromised patient, should investigate this difficult-to-treat pathogen.

Multicentric Case Series and Literature Review of Coccidioidal Otomastoiditis

Coccidioidomycosis involving the ear, mastoid bone, or both is uncommon. We describe 5 new cases from the United States and review 4 cases reported in the literature of otomycosis and mastoiditis caused by Coccidioides. Of the 9 cases, 8 were linked to residence in or travel to California. Two patients had poorly controlled diabetes mellitus, 7 had otomastoiditis, 1 had otitis externa without mastoid involvement, and 1 had mastoiditis without otic involvement. Four patients had concurrent or prior pulmonary coccidioidomycosis. Ipsilateral facial nerve palsies developed in 2 patients. All patients received antifungal treatment for varying durations, and 8 of the 9 patients underwent surgical debridement. Clinicians should consider coccidioidomycosis as a differential diagnosis for otomastoiditis in patients with geographic risks.

Sino-orbital aspergillosis with obstructive cervical lymphadenopathy in a cat caused by Aspergillus viridinutans complex

Case summary

This report describes an indoor-only cat with a rare form of sino-orbital aspergillosis (SOA) with cervical lymphadenopathy causing local obstruction. Extensive work-up on initial presentation failed to identify the underlying etiology and the diagnosis was not determined until the disease progressed during a prolonged course of glucocorticoid therapy.

Relevance and novel information

SOA caused by Aspergillus viridinutans complex is increasingly recognized as a significant cause of mortality in cats in recent years, with most cases reported in Australia, Europe and Asia. Feline SOA carries a poor prognosis owing to its invasive nature and resistance to antifungal therapy. This case demonstrates the importance of clinical awareness of SOA as a differential for cats with chronic nasal signs and exophthalmos in the USA. Moreover, it demonstrates a rare form of presentation and potential difficulty in achieving a correct diagnosis.

Diagnosis and Management of Severe Water-Related Skin and Soft Tissue Sepsis: A Summative Review of the Literature

BACKGROUND

Skin and soft tissue infections (SSTIs) are common presentations in the emergency department. However, this is less common after contact with contaminated saltwater or freshwater. This review presents the diagnosis and management of water-related soft tissue sepsis in this vulnerable and difficult-to-treat subgroup of necrotizing soft tissue sepsis.

METHODS

A summative literature overview is presented regarding bacterial and fungal SSTI after contact with contaminated water, with practical diagnostic and management aspects.

RESULTS

The literature indicates that these wounds and infections remain difficult to treat. An approach using appropriate diagnostic tools with both medical and surgical management strategies is provided.

CONCLUSIONS

SSTIs due to water contamination of wounds involve unusual organisms with unusual resistance patterns, and require a nuanced and directed diagnostic approach with an adaptation of the usual antibiotic or antifungal selection to achieve a successful cure, along with aggressive debridement and wound care.

Blood Stream Infections in Burns: A 14-Year Cohort Analysis

BACKGROUND

Blood stream infections are a significant cause of morbidity and mortality in burns, and pathogen identification is important for treatment. This study aims to characterize the microbiology of these infections and the association between the infecting pathogen and the hospitalization course.

METHODS

We conducted a cohort study that included records of burn patients treated at the Soroka University Medical Center between 2007-2020. Statistical analysis of demographic and clinical data was performed to explore relationships between burn characteristics and outcomes. Patients with positive blood cultures were divided into four groups: Gram-positive, Gram-negative, mixed-bacterial, and fungal.

RESULTS

Of the 2029 burn patients hospitalized, 11.7% had positive blood cultures. The most common pathogens were Candida and Pseudomonas. We found significant differences in ICU admission, need for surgery, and mortality between the infected and non-infected groups (p < 0.001). Pathogen groups differed significantly mean TBSA, ICU admission, need for surgery, and mortality (p < 0.001). Multivariate analysis showed flame (OR 2.84) and electric burns (OR 4.58) were independent risk factors for ICU admission and surgical intervention (p < 0.001). Gram-negative bacterial infection was found to be an independent predictor of mortality (OR = 9.29, p < 0.001).

CONCLUSIONS

Anticipating specific pathogens which are associated with certain burn characteristics may help guide future therapy.

Biogeographic Patterns of Fungal Sub-Communities under Different Land-Use Types in Subtropical China

Revealing the regional distribution and diversity of fungal sub-communities under different land management practices is essential to conserve biodiversity and predict microbial change trends. In this study, a total of 19 tilled and 25 untilled soil samples across different land-use types were collected from subtropical China to investigate the differences between the spatial distribution patterns, diversity, and community assembly of fungal sub-communities using high-throughput sequencing technology. Our results found that anthropogenic disturbances significantly reduced the diversity of abundant taxa but significantly increased the diversity of rare taxa, suggesting that the small-scale intensive management of land by individual farmers is beneficial for fungal diversity, especially for the conservation of rare taxa. Abundant, intermediate, and rare fungal sub-communities were significantly different in tilled and untilled soils. Anthropogenic disturbances both enhanced the homogenization of fungal communities and decreased the spatial-distance-decay relationship of fungal sub-communities in tilled soils. Based on the null model approach, the changes in the assembly processes of the fungal sub-communities in tilled soils were found to shift consistently to stochastic processes, possibly as a result of the significant changes in the diversity of those fungal sub-communities and associated ecological niches in different land-use types. Our results provide support for the theoretical contention that fungal sub-communities are changed by different land management practices and open the way to the possibility of predicting those changes.

The Radiological Spectrum of Rhino-Oculo-Cerebral Mucormycosis

Aim We aim to study the spectrum of imaging findings in patients with rhino-oculo-cerebral mucormycosis (ROCM). Materials and methods This retrospective descriptive study was performed in histopathologically confirmed cases of rhino-oculo-cerebral mucormycosis in a tertiary care center in Bihar, India. The case records of patients with radiological, cultural, and histological evidence of acute invasive ROCM were retrospectively evaluated for relevant radiological and clinical data between May 2021 and June 2022. Results The radiological evaluation included computed tomography (CT) and magnetic resonance imaging (MRI) scans done on 52 patients. The patient's average age was 48 years. The ethmoid sinus was involved in 51 (98%) cases and the maxillary sinus in 50 (96%) cases. Bilateral sinus involvement (45, 86%) was the most common, followed by pansinus involvement (27, 52%). The orbit was involved in 39 (75%) cases, the face in 25 (47%) cases, and retroantral fat stranding in 24 (46%) cases. Mucosal thickening (91%) was the most common pattern of involvement, followed by complete opacification (77%). Osseous involvement was seen in 17 of 44 patients who had CT scans, and the majority of patients had extrasinus extension with intact bone. MRI revealed variable T2SI, with T2 hyperintensity being the most common pattern. Heterogeneous enhancement in post-contrast imaging was the most common. Conclusion ROCM is a life-threatening invasive fungal infection, especially in an immunocompromised state. ROCM is characterized by a variety of imaging abnormalities on CT and MRI, although nonspecific. Imaging aids in suspicion or early diagnosis in appropriate clinical contexts, particularly in an immunocompromised state, and in determining the degree of involvement and complications. Early detection of ROCM and its complications enables proper treatment, which can lower the cost of care, morbidity, and mortality.

Fungal quorum-sensing molecules and antiseptics: a promising strategy for biofilm modulation?

New strategies to control fungal biofilms are essential, especially those that interfere in the biofilm organization process and cellular communication, known as quorum sensing. The effect of antiseptics and quorum-sensing molecules (QSMs) have been considered with regard to this; however, little has been elucidated, particularly because studies are often restricted to the action of antiseptics and QSMs against a few fungal genera. In this review, we discuss progress reported in the literature thus far and analyze, through in silico methods, 13 fungal QSMs with regard to their physicochemical, pharmacological, and toxicity properties, including their mutagenicity, tumorigenicity, hepatotoxicity, and nephrotoxicity. From these in silico analyses, we highlight 4-hydroxyphenylacetic acid and tryptophol as having satisfactory properties and, thus, propose that these should be investigated further as antifungal agents. We also recommend future in vitro approaches to determine the association of QSMs with commonly used antiseptics as potential antibiofilm agents.

Incidence of acute kidney injury in dogs with systemic mycotic infections treated with amphotericin B (1996-2020)

BACKGROUND

Amphotericin-B (AmB) is an essential medication for the treatment of life-threatening systemic mycoses but the incidence and risk factors for acute kidney injury (AKI) after its administration are not known in dogs.

OBJECTIVE

Determine the incidence of and risk factors for AKI in dogs receiving AmB.

ANIMALS

Fifty-one client owned dogs receiving AmB for the treatment of systemic mycoses.

METHODS

Retrospective study. Signalment, potential risk factors, AKI development (creatinine ≥0.3 mg/dL from baseline), drug formulation (deoxycholate [AmB-D] or lipid complex [ABLC]), dose, and treatment duration were recorded. The probability of an AKI diagnosis was evaluated using a log-rank test. The incidence of AKI and odds ratios were calculated for potential risk factors.

RESULTS

Incidence of AKI was 5/12 (42%) for dogs receiving AmB-D and 14/39 (36%) for dogs receiving ABLC. Of the 19 dogs that developed AKI, 16 (84%) continued treatment after a pause in the planned dosing protocol. Fifty percent of dogs received a cumulative dose of 6.9 mg/kg for AmB-D and 22.5 mg/kg for ABLC (P < .01) at time of AKI diagnosis. ICU hospitalization (odds ratio [OR] 0.21, 95% confidence interval [CI]: 0.58-0.87) and inpatient status (OR 0.25, 95% CI: 0.07-0.86) were associated with decreased odds of AKI.

CONCLUSIONS AND CLINICAL IMPORTANCE

Incidence of AKI with AmB is common but does not always preclude continued treatment. The incidence of AKI is similar between AmB-D and ABLC, but dogs receiving ABLC tolerated a higher cumulative total dose before AKI diagnosis.

Accidental finding of COVID-associated mucormycosis (CAM) in a patient presenting as toothache: A case report and review of literature

Mucormycosis is an angio-invasive rapidly progressing fungal infection, usually reported in immunocompromised individuals. We present a case of COVID-associated mucormycosis in a patient with a presenting symptom of toothache in the maxilla with a possible mild case of COVID-19.

Abstract

Coronavirus-associated mucormycosis (CAM) had reached epidemic status, especially during the second wave of COVID-19. It was especially prevalent in India with a large mortality rate. Mucormycosis, particularly the rhinocerebral type is seen to be greatly associated with COVID-19, especially in patients with altered immunity. Uncontrolled diabetes, chronic kidney disease, immunocompromised patients, malignant hematological diseases, etc. are the major risk factors of CAM, precipitated by the injudicious use of corticosteroids for the treatment of COVID-19. CAM may often present in the maxillofacial region which warrants that dental clinicians be aware of the clinical presentation, diagnostic guidelines, and appropriate management measures for the disease. This report is one such case of CAM involving the posterior maxilla in a middle-aged individual with mild COVID-19 symptoms.

Validation of an expanded, in-house library and an optimized preparation method for the identification of fungal isolates using MALDI-TOF mass spectrometry

The goal of this study was to validate an optimized sample preparation method for filamentous fungal isolates coupled with the use of an in-house library for the identification of moulds using Matrix Assisted Laser Desorption/Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS) in a multicenter context. For that purpose, three Spanish microbiology laboratories participated in the identification of 97 fungal isolates using MALDI-TOF MS coupled with the Filamentous Fungi library 3.0 (Bruker Daltonics) and an in-house library containing 314 unique fungal references. The isolates analyzed belonged to 25 species from the genus Aspergillus, Fusarium, Scedosporium/Lomentospora, the Mucorales order and the Dermatophytes group. MALDI-TOF MS identification was carried out from hyphae resuspended in water and ethanol. After a high-speed centrifugation step, the supernatant was discarded and the pellet submitted to a standard protein extraction step. The protein extract was analyzed with the MBT Smart MALDI Biotyper system (Bruker Daltonics). The rate of accurate, species-level identification obtained ranged between 84.5% and 94.8% and the score values were 1.8 for 72.2-94.9% of the cases. Two laboratories failed to identify only one isolate of Syncephalastrum sp. and Trichophyton rubrum, respectively and three isolates could not be identified in the third center (F. proliferatum, n = 1; T.interdigitale, n = 2). In conclusion, the availability of an effective sample preparation method and an extended database allowed high rates of correct identification of fungal species using MALDI-TOF MS. Some species, such as Trichophyton spp. are still difficult to identify. Although further improvements are still required, the developed methodology allowed the reliable identification of most fungal species.

Updated estimation of the burden of fungal disease in Vietnam

BACKGROUND

Anecdotally, the burden of fungal diseases in Vietnam is rapidly rising, but there has been no updated estimate on this issue since a previous report in 2015.

OBJECTIVES

In this study, we aimed at estimating the incidence and prevalence of serious fungal infections for the year 2020.

METHODS

We made estimates with a previously described methodology, using reports on the incidence and prevalence of various established risk factors for fungal infections from local, regional or global sources.

RESULTS

We estimated 2,389,661 cases of serious fungal infection occurred in Vietnam in 2020. The most common condition was recurrent vaginal candidiasis (4047/100,000 women annually). Among people living with HIV, we estimated 451 cases of cryptococcal meningitis, 1030 of pneumocystis pneumonia, 166 of histoplasmosis and 1612 of talaromycosis annually. Candidaemia incidence was estimated at 12/100,000 population each year. Owing to its high burden of tuberculosis and respiratory diseases, Vietnam had high rates of severe infections caused by Aspergillus species. Incidence of invasive aspergillosis is 24/100,000 population, allergic bronchopulmonary aspergillosis 78/100,000 and severe asthma with fungal sensitisation 102/100,000. Five-year period prevalence of chronic pulmonary aspergillosis is 120/100,000 population /5-year period. Mucormycosis, fungal keratitis and tinea capitis were estimated at 192, 14,431 and 201 episodes each year, respectively.

CONCLUSIONS

The number of patients with mycoses in Vietnam is likely underestimated due to a lack of local data and limited diagnostic capacity, but at least 2.5% of the population might have some form of serious fungal disease.

New Developments in Allergic Fungal Rhinosinusitis Pathophysiology and Treatment

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is an endotype of chronic rhinosinusitis (CRS) with nasal polyps characterized by eosinophilic mucin laden with fungal hyphae entrapped in expanded sinus cavities with an exaggerated hypersensitivity to fungal elements. The last decade has elucidated fungi-driven inflammatory pathways contributing to the pathophysiology of chronic inflammatory respiratory diseases. In addition, novel therapeutic biologic options have become available for CRS over the last several years.

OBJECTIVE

To review the current literature examining AFRS, focusing on recent developments in our understanding of its pathophysiology and implications for treatment options.

METHODS

Review article.

RESULTS

Fungi-driven respiratory inflammation has been linked to fungal proteinases and toxin activity. In addition, AFRS patients demonstrate a local sinonasal immunodeficiency in antimicrobial peptides and hence limited antifungal activity, along with an exaggerated type 2 inflammatory response, highlighting a possible imbalanced type 1, type 2, and type 3 profile. The elucidation of these dysregulated molecular pathways has highlighted novel potential therapeutic targets. As such, the clinical management of AFRS, which once included surgery and extended courses of oral corticosteroids, is transitioning away from long courses of oral corticosteroids to incorporate novel delivery mechanisms of topical therapeutic targets and biologics for recalcitrant disease.

CONCLUSION

AFRS is an endotype of CRS with nasal polyps (CRSwNP) for which the molecular pathways leading to its inflammatory dysfunction are beginning to be illuminated. In addition to affecting treatment options, these understandings may shape necessary changes to diagnostic criteria and the extrapolated effects of environmental changes on AFRS. More critically, a better appreciation of fungi-driven inflammatory pathways may have implications for the understanding of broader CRS inflammation.