Sporothrix brasiliensis Causing Atypical Sporotrichosis in Brazil: A Systematic Review

Zoonotic sporotrichosis, a subcutaneous mycosis caused by Sporothrix brasiliensis, has become hyperendemic and a serious public health issue in Brazil and an emerging disease throughout the world. Typical sporotrichosis is defined as fixed or lymphocutaneous lesion development, however, reports of atypical presentations have been described in hyperendemic areas, which may result in a worse prognosis. Thus, considering an increase in atypical cases and in more severe extracutaneous cases and hospitalizations reported in Brazil, we aimed to perform a systematic review to search for hypersensitivity reactions (HRs) and extracutaneous presentations associated with zoonotic sporotrichosis. A systematic review was performed, following the PRISMA guidelines to search for atypical/extracutaneous cases (mucosal, osteoarthritis, HRs, pulmonary, meningeal) of zoonotic sporotrichosis. A total of 791 published cases over 26 years (1998-2023) in eleven Brazilian states were reviewed. Most cases corresponded to a HR (47%; n = 370), followed by mucosal (32%; n = 256), multifocal (8%; n = 60), osteoarthritis (7%; n = 59), meningeal (4%; n = 32), and pulmonary (2%; n = 14) infections. When available (n = 607), the outcome was death in 7% (n = 43) of cases. Here, we show a frequent and worrisome scenario of zoonotic sporotrichosis in Brazil, with a high and dispersed incidence of atypical/extracutaneous cases throughout the Brazilian territory. Therefore, educational measures are necessary to make health professionals and the overall population aware of this fungal pathogen in Brazil as well as in other countries in the Americas.

Optimization of a commercial Histoplasma galactomannan EIA test in a population from an endemic area of histoplasmosis in southern Brazil

BACKGROUND

Since 2020 the World Health Organization (WHO) recommends Histoplasma antigen detection for the diagnosis of disseminated histoplasmosis (DH) in people living with HIV (PLHIV).

OBJECTIVE

Here we aimed to optimise the IMMY's Clarus® Histoplasma GM enzyme immunoassay (EIA), evaluating the best cut-off in the semi-quantitative (SQ-HGM EIA), also known as 'calibrator cut-off procedure'.

METHODS

The optimization was done using the quantitative standard procedure (Q-HGM EIA), also known as 'standard curve procedure', as reference test. A retrospective study from an endemic area of DH in southern Brazil was carried out including 264 patients investigated for DH using the test. Receiver Operator Characteristic curve was plotted, and sensitivity and specificity of the SQ-HGM EIA were calculated.

RESULTS

The study included 24 positive (values ≥ 0.20 ng/ml) and 240 negative patients by the Q-HGM EIA. According to the manufacturer SQ-HGM EIA protocol, the new SQ-HGM EIA cut-off of 0.8 EIA units was validated, resulting in sensitivity and specificity of 88% and 98.7%, respectively.

CONCLUSION

Our study pioneers and brings important data about the optimization of the Histoplasma antigen testing for the diagnosis of DH in a population from Southern Brazil. This optimization also reduced the amount of reagents used, lowering the cost associated with testing.

Latent tuberculosis screening before kidney transplantation in the South of Brazil

Background:

Tuberculosis (TB) is a prevalent infection after kidney transplantation (KT) in high-burden countries. Latent tuberculosis infection (LTBI) screening includes previous TB history, chest radiograph findings, and tuberculin test (TST) and/or interferon-gamma release assays (IGRAs) results. We aimed to compare our routine LTBI screening of KT candidates and living donors (LD) with their IGRA results, and evaluate if this would improve isoniazid (INH) treatment referral.

Methods:

We evaluated adult KT candidates and LD with complete routine LTBI screening and QuantiFERON-TB® Gold In-Tube (QFT) testing. Blood samples were collected from April 4th, 2014 to October 31st, 2018, with follow-up until October 31st, 2019.

Results:

There were 116 KT recipients, with 30% QFT-positive results. Positive QFT was associated with past TB history (p=0.007), positive TST (p<0.0001), residual radiographic lesions (p=0.003), and diabetes (p=0.035). There were 25 LD, 40% had positive QFT. Positive QFT was associated with a positive TST (p=0.002). Positive QFT results increased INH referral in 80%. Post-transplant TB incidence was 2.6% in a median follow-up of 2 (1-33) months. No variables were associated with post-transplant TB. TB patients had inferior, although non-significant, 5-year graft survival (66.7% vs. 76.5%) (p = 0.402).

Conclusion:

In the present study, the association of QFT to our routine LTBI screening incremented INH treatment referral, but there was still a high incidence of post-transplant TB, possibly related to other forms of infection, such as new exposure and donor transmission.

Koilocytes due to HPV in the urine sediment

Koilocytes are the hallmark of human papillomavirus (HPV) infection and can be observed during routine cytology tests stained by Papanicolaou. However, the test is not part of the routine urinalysis report. Here we describe a case on HPV subtype 6 infection diagnosed after finding koilocytes in fresh and unstained urine sediment of a kidney allograft recipient male patient.

COVID-19-Associated Histoplasmosis in an AIDS Patient

Most reports associating fungal infections with COVID-19 have been cases of invasive aspergillosis. Here, we report a case of severe histoplasmosis and COVID-19 infections in an HIV patient in Rio Grande, Southern Brazil. Histoplasmosis must be included as a diagnostic possibility in opportunistic fungal co-infections in COVID-19 patients with AIDS, mainly in endemic areas.

The halo sign: HRCT findings in 85 patients

Objective:

The halo sign consists of an area of ground-glass opacity surrounding pulmonary lesions on chest CT scans. We compared immunocompetent and immunosuppressed patients in terms of halo sign features and sought to identify those of greatest diagnostic value.

Methods:

This was a retrospective study of CT scans performed at any of seven centers between January of 2011 and May of 2015. Patients were classified according to their immune status. Two thoracic radiologists reviewed the scans in order to determine the number of lesions, as well as their distribution, size, and contour, together with halo thickness and any other associated findings.

Results:

Of the 85 patients evaluated, 53 were immunocompetent and 32 were immunosuppressed. Of the 53 immunocompetent patients, 34 (64%) were diagnosed with primary neoplasm. Of the 32 immunosuppressed patients, 25 (78%) were diagnosed with aspergillosis. Multiple and randomly distributed lesions were more common in the immunosuppressed patients than in the immunocompetent patients (p < 0.001 for both). Halo thickness was found to be greater in the immunosuppressed patients (p < 0.05).

Conclusions:

Etiologies of the halo sign differ markedly between immunocompetent and immunosuppressed patients. Although thicker halos are more likely to occur in patients with infectious diseases, the number and distribution of lesions should also be taken into account when evaluating patients presenting with the halo sign.

Thrombin activatable fibrinolysis inhibitor as a bleeding predictor in liver transplantation: a pilot observational study

OBJECTIVE

To correlate the levels of thrombin activatable fibrinolysis inhibitor in the immediate postoperative period and at 24 hours postoperatively with the volume of intraoperative bleeding.

METHODS

Twenty-one patients allocated immediately before (elective or emergency) liver transplantation were analyzed. Blood samples were collected for thrombin activatable fibrinolysis inhibitor analysis at three different time points: immediately before liver transplantation (preoperative thrombin activatable fibrinolysis inhibitor), immediately after the surgical procedure (immediate postoperative thrombin activatable fibrinolysis inhibitor), and 24 hours after surgery (thrombin activatable fibrinolysis inhibitor 24 hours after surgery). The primary outcome of the study was to correlate the preoperative and immediate postoperative levels of thrombin activatable fibrinolysis inhibitor with intraoperative blood loss.

RESULTS

There was a correlation between the preoperative thrombin activatable fibrinolysis inhibitor levels and bleeding volume (ρ = -0.469; p = 0.05) but no correlation between the immediate postoperative thrombin activatable fibrinolysis inhibitor and bleeding volume (ρ = -0.062; p = 0.79). No variable included in the linear regression analysis (prehemoglobin, prefibrinogen and preoperative thrombin activatable fibrinolysis inhibitor) was a bleeding predictor. There was a similar trend in the variation between the levels of thrombin activatable fibrinolysis inhibitor at the three different time points and fibrinogen levels. Patients who died within 6 months (14.3%) showed decreased preoperative and immediate postoperative levels of thrombin activatable fibrinolysis compared with survivors (preoperative: 1.3 ± 0.15 versus 2.55 ± 0.53, p = 0.06; immediate postoperative: 1.2 ± 0.15 versus 2.5 ± 0.42, p = 0.007).

CONCLUSION

There was a moderate correlation between preoperative thrombin activatable fibrinolysis inhibitor and intraoperative bleeding in liver transplantation patients, although the predictive role of this variable independent of other variables remains uncertain. Preoperative and immediate postoperative thrombin activatable fibrinolysis inhibitor levels may have a role in the survival prognosis of this population; however, this possibility requires confirmation in further studies with larger sample sizes.

Correlation between the presence of degenerated inclusion-bearing cells in voided urine samples and the occurrence of polyomavirus infection

OBJECTIVE

The purpose of the present, prospective, cohort study was to monitor urine cytology samples from recipients of renal transplants to search for the occurrence of decoy cells and degenerated inclusion-bearing cells with an aim to correlate the existence of these cells with molecular detection of polyomavirus BK (BKV) DNA in urine.

MATERIAL AND METHODS

This study included patients who underwent renal transplantation. Patients had their urine tested quarterly, during the first year post-transplantation, for the presence of decoy cells and degenerated cells, as well as by quantitative determination of BKV load in the urine and plasma.

RESULTS

Three hundred and sixty-one examinations were performed on 101 patients within 12 months of attendance. Urine cytology results were: 198 (54.9%) negative and 60 (16.6%) positive for the presence of viral cytopathic effects depending on the presence of BKV infection, 72 (19.9%) positive for the manifestation of degenerated cells and 31 (8.6%) unsatisfactory for analysis. There was a subtle tendency towards the presence of degenerated inclusion-bearing cells in cases in which the virus was detected in voided urine. However, the presence of degenerated cells exhibited a tendency to BKV positivity in months 3, 6 and 9 and, exclusively in month 12, this trend was statistically significant.

CONCLUSIONS

There were not enough strong morphological and staining elements to state the origin of the degenerated cells or to describe the nature of the infection (viral or bacterial), given that these cells were undergoing an apoptotic process in post renal transplant patients.

Disseminated histoplasmosis and AIDS: a prospective and multicentre study to evaluate the performance of different diagnostic tests

The burden of histoplasmosis has been poorly documented in most of the endemic areas for the disease, including Brazil. Also, modern non-culture-based diagnostic tests are often non-available in these regions. This was a prospective cohort study in HIV-infected patients with suspected disseminated disease evaluated with different diagnostic tests. Patients were enrolled in three referral medical centres in Porto Alegre, Brazil. Among 78 evaluated patients, disseminated histoplasmosis was confirmed in eight individuals (10.3%) by the means of classical (culture/histopathology) tests. Antigen detection in the urine was found to be more sensitive: IMMY^® ALPHA ELISA detected 13 positive cases (16.7%) and the in-house ELISA test developed by the Centers for Disease Prevention and Control (CDC) detected 14 (17.9%). IMMY^® and CDC tests provided concordant results in 96.2% of cases. This is the first study to compare the performance of the in-house CDC ELISA test with the IMMY^® commercial test for the diagnosis of histoplasmosis, and a high degree of concordance was observed. The study revealed that H. capsulatum is an important agent of disseminated disease in AIDS patients in Brazil, reinforcing the importance of making available modern diagnostic tests as well as safer antifungal agents for the treatment of histoplasmosis.

An Outbreak ofPichia anomalaFungemia in a Brazilian Pediatric Intensive Care Unit

Objective:

To report an outbreak ofPichia anomalafungemia that occurred in a Brazilian pediatric intensive care unit (ICU) from October 2002 to January 2004.

Design:

Unmatched case-control study.

Methods:

We randomly selected four control-patients for each case-patient from a list of all patients admitted to the ICU for at least 48 hours during the outbreak. A second control group was composed of all consecutive patients with nosocomial candidemia in the ICU during the outbreak. An environmental study was performed, and genetic relatedness among the clinical isolates was characterized by randomly amplified polymorphic DNA assay.

Results:

During the study period, 1,046 children were admitted to the pediatric ICU, 17 of whom developedP. anomalafungemia (attack rate, 1.6%). The median age was 1.1 years, and the main underlying conditions were congenital malformations (35.3%) and neoplastic diseases (11.8%). The overall mortality rate was 41.2%. Two patients received no antifungal treatment; all of the others were treated with amphotericin B. On multivariate analysis, only the presence of a central venous catheter was significantly associated withP. anomalafungemia. The yeast was not found on healthcare workers' hands or in the environment. Molecular studies showed that the outbreak was caused by a single strain. The distribution of risk factors was similar between patients withP. anomalafungemia and control-patients with candidemia.

Conclusions:

This study highlights the importance ofP. anomalaas an emerging nosocomial fungal pathogen. Patients withP. anomalafungemia seem to have risk factors in common with those who have candidemia.

Thrombin-activatable Fibrinolysis Inhibitor (TAFI) as a Novel Prognostic Factor After Orthotropic Liver Transplantation: A Pilot Study

BACKGROUND

Thrombin-activatable fibrinolysis inhibitor (TAFI), a liver-produced coagulation factor, has been associated with higher mortality in cirrhotic patients, but there has not been any description of its role in perioperative care in liver transplantation cases.

METHODS

A total of 21 patients were included. Serum TAFI levels were determined at 3 time points: preoperatively (TAFI pre), immediately postoperative (TAFI PO), and 24 hours postoperatively (TAFI 24 h). The main outcome was the physiological pattern of TAFI in the perioperative period of liver transplantation. The secondary outcomes were the association between TAFI and early allograft dysfunction (EAD) as well as that of TAFI and 6-month mortality.

RESULTS

TAFI levels increased at the 24-hour time point, compared to the other 2 time points (TAFI pre, P = .007; TAFI PO, P = .0001). Early allograft dysfunction occurred in 2 of 21 patients, both demonstrating lower TAFI 24 h levels compared to those who did not develop this complication (3.0 ± 0.2 vs 1.5 ± 0.3; P = .0001). Three patients who died all demonstrated lower levels of TAFI pre (1.3 ± 0.1 vs 2.5 ± 0.5; P = .001) and TAFI PO (1.2 ± 0.1 vs 2.4 ± 0.4; P = .001) compared to the survivors.

CONCLUSIONS

These findings suggest that the determination of TAFI levels-both pre- and postoperatively-may be of clinical relevance in liver transplant recipients.

Prospective multicenter international surveillance of azole resistance in Aspergillus fumigatus

To investigate azole resistance in clinical Aspergillus isolates, we conducted prospective multicenter international surveillance. A total of 3,788 Aspergillus isolates were screened in 22 centers from 19 countries. Azole-resistant A. fumigatus was more frequently found (3.2% prevalence) than previously acknowledged, causing resistant invasive and noninvasive aspergillosis and severely compromising clinical use of azoles.

Risk factors for hepatotoxicity in solid organ transplants recipients being treated for tuberculosis

BACKGROUND

Tuberculosis (TB) is associated with high morbidity and mortality in solid organ transplant (SOT) recipients. Also, SOT patients have a 20- to 74-fold increase in the chance of developing TB compared to the general population. Here we evaluated the incidence of hepatotoxicity in SOT recipients on treatment for TB and determined risk factors for liver toxicity in these patients.

PATIENTS AND METHODS

Retrospective cohort conducted in a reference hospital for SOT in Southern Brazil. All SOT recipients who underwent TB treatment during the years 2000-2012 were considered for the study.

RESULTS

A total of 69 patients were included in the study and 23 had liver toxicity (incidence 33.3%). Independent risk factors for hepatotoxicity were rifampin use at doses of ≥600 mg daily (P = .016; OR 2.47; 95% CI, 1.18-5.15) and lung transplantation (P = .017; OR 2.05; 95% CI, 1.14-3.70). Kidney transplantation appeared as a protective factor (P = .036; OR 0.50; 95% CI, 0.26-0.96). Mortality was higher in the patients who had hepatotoxicity (43.5%), compared with those who did not (19.6%).

CONCLUSION

In this study, the use of rifampin at doses of 600 mg daily or higher was found to be an independent risk factor for liver toxicity in SOT recipients. The importance of additional risk factors for hepatotoxicity, such as lung transplantation as well as the protective role of kidney transplantation, should be better investigated in SOT recipients being treated for TB.

A search for Clostridium difficile ribotypes 027 and 078 in Brazil

Toxigenic strains of Clostridium difficile may be disseminating. Here we prospectively screened patients with nosocomial diarrhoea in two hospitals in Brazil. To identify C. difficile polymerase chain reaction ribotypes 027/078 strains, we used high resolution melting and multiplex polymerase chain reaction. Among 116 screened patients, 11 were positive for C. difficile. The polymerase chain reaction ribotypes 027/078 strains were not identified in this study.

Invasive candidosis: contrasting the perceptions of infectious disease physicians and intensive care physicians

INTRODUCTION

We analyze how infectious disease physicians perceive and manage invasive candidosis in Brazil, in comparison to intensive care unit specialists.

METHODS

A 38-question survey was administered to 56 participants. Questions involved clinicians’ perceptions of the epidemiology, diagnosis, treatment and prophylaxis of invasive candidosis. P < 0.05 was considered statistically significant.

RESULTS

The perception that candidemia not caused by Candida albicans occurs in less than 10% of patients is more commonly held by intensive care unit specialists (p=0.018). Infectious disease physicians almost always use antifungal drugs in the treatment of patients with candidemia, and antifungal drugs are not as frequently prescribed by intensive care unit specialists (p=0.006). Infectious disease physicians often do not use voriconazole when a patient’s antifungal treatment has failed with fluconazole, which also differs from the behavior of intensive care unit specialists (p=0.019). Many intensive care unit specialists use fluconazole to treat candidemia in neutropenic patients previously exposed to fluconazole, in contrast to infectious disease physicians (p=0.024). Infectious disease physicians prefer echinocandins as a fi rst choice in the treatment of unstable neutropenic patients more frequently than intensive care unit specialists (p=0.013). When candidemia is diagnosed, most infectious disease physicians perform fundoscopy (p=0.015), whereas intensive care unit specialists usually perform echocardiograms on all patients (p=0.054).

CONCLUSIONS

This study reveals a need to better educate physicians in Brazil regarding invasive candidosis. The appropriate management of this disease depends on more drug options being available in our country in addition to global coverage in private and public hospitals, thereby improving health care.

Prolonged respiratory viral shedding in transplant patients

Respiratory viral infections are frequent causes of morbidity in transplant patients. We screened symptomatic adult transplant recipients for respiratory viruses in a cohort of patients attending a referral medical center in Brazil. The duration of viral shedding and the prevalence of viral codetections were also determined. During a 1‐year period (2011–2012), swabs were obtained from 50 patients. An in‐house polymerase chain reaction panel designed to detect 10 viruses was used. Viruses were identified in 19 (38%) patients, particularly parainfluenza III (32%) and the respiratory syncytial virus (20%); multiple viruses were identified in 26% of patients. Prolonged viral shedding was observed with 60% of individuals excreting viruses for >10 days. The clinical and epidemiologic relevance of prolonged viral shedding remains to be determined.

Variability in Galactomannan detection by Platelia Aspergillus EIA™ according to the Aspergillus species

Here we investigate the extent to which different Aspergillus species release galactomannan (GM) in vitro. Marked variability was observed in GM reactivity between and within Aspergillus species, with A. terreus strains showing the highest GM indexes. The in vivo significance of these findings remains to be determined.

Saccharomyces cerevisiae oesophagitis in a patient with oesophageal carcinoma

Saccharomyces species are emerging opportunistic fungal pathogens that can cause bloodstream infections in humans. These infections have often been associated with the ingestion of probiotics. Saccharomyces oesophagitis is a rare condition which has been described so far in only two publications. Here we report the case of a patient who was diagnosed with Saccharomyces oesophagitis. The clinical picture was indistinguishable from that of Candida oesophagitis. The Saccharomyces isolate was shown to be susceptible to fluconazole by both CLSI M27-A and disk diffusion methods. In contrast to cases of fungaemia, Saccharomyces oesophagitis does not seem to follow probiotic use. Due to the potential for antifungal resistance among emerging fungal pathogens, proper mycological identification at the species level is essential.

Drinking yerba mate infusion: a potential risk factor for invasive fungal diseases?

Yerba mate (Ilex paraguariensis) infusion is a very popular drink in South America. Although several studies have evaluated the potential for fungal contamination in foodstuff, very few investigations have been conducted with yerba mate samples. In order to evaluate for the presence of potentially pathogenic fungi, here we studied 8 brands of yerba mate commercially available in Southern Brazil. Fungal survival in adverse conditions such as gastric pH was determined by incubating samples at pH 1.5. Because hot water is generally used to prepare yerba mate infusion, the effect of several temperatures on fungal growth was also investigated. All but 1 yerba mate brand showed substantial fungal growth, in the range of <10–4900 colony-forming units per gram. Some of these fungi were able to survive extreme variations in pH and temperature. Because of the potential for yerba mate to carry pathogenic fungi, immunocompromised patients may be at risk of acquiring invasive fungal diseases by drinking yerba mate infusion.

Galactomannan detection from piperacillin-tazobactam brands available in the Brazilian market

Piperacillin-tazobactam is a broad spectrum antimicrobial agent that can cause false-positive results in the commercial Platelia Aspergillus EIA test. So far, no study has been performed in Latin America to evaluate the clinical implication of this finding. Here we studied the potential for galactomannan detection in piperacillin-tazobactam batches commercialized in the Brazilian market. Five batches from distinct laboratories were tested in duplicate in the Platelia Aspergillus EIA according to the manufacturer's instructions. Only one drug showed crossreaction at a cut-off of 0.5. Human serum was spiked with this particular drug aiming to mimic achievable piperacillin-tazobactam concentrations in the serum. Results were all negative for galactomannan detection, even at high drug concentrations. Results from this pilot study suggest that piperacillin-tazobactam might not be a clinically significant cause of false-positive results in the Platelia Aspergillus EIA test in Brazil.

Distribution of filamentous fungi causing invasive fungal disease at the Haematological Unit, Hospital de Clínicas de Porto Alegre, Brazil

Very limited data are available in the literature to elucidate the aetiology of invasive mould infections in Latin America. Here we report that Aspergillus species caused only half of such cases in a cohort study conducted over 21 months in a university hospital in Porto Alegre, Southern Brazil. Fusarium spp. were the second most prevalent moulds (20.7%), followed by Zygomycetes (13.8%). The importance of obtaining local epidemiological data for adequately guiding empirical antifungal therapy is reinforced.

Candida esophagitis: species distribution and risk factors for infection

Although Candida albicans is the main cause of fungal esophagitis, other species such as C. tropicalis, C. krusei and C. stellatoidea have also been implicated. Several studies have identified risk factors for C. albicans esophagitis. However, data for non-C. albicans species is still sparse. The aim of this study was to determine the etiology of Candida esophagitis in our medical centre over an 18-month period. Additionally, we aimed to investigate predisposing conditions for esophageal candidosis caused by different Candida species. A total of 21,248 upper gastroscopies were performed in Santa Casa Complexo Hospitalar between January 2005 and July 2006. The prevalence of Candida esophagitis was 0.74% (n = 158). C. albicans caused the vast majority of infections (96.2%), followed by C. tropicalis (2.5%), C. lusitaniae (0.6%) and C. glabrata (0.6%). There were 81 women (51.3%) and 77 men (48.7%). No case of mixed infection occurred. Concomitant oral candidosis was documented for 10.8% (n = 17). Most of cases (55.1%) involved outpatients. Around one fifth of patients in our cohort had no identifiable risk factors for esophageal candidosis (20.8%). Since nearly all infections were caused by C. albicans we were not able to determine risk factors for esophagitis caused by other Candida species.

Invasive pulmonary aspergillosis due to a mixed infection caused by Aspergillus flavus and Aspergillus fumigatus

Invasive pulmonary aspergillosis is typically caused by a single Aspergillus species, most frequently Aspergillus fumigatus. Here we report that a lung transplant recipient developed invasive aspergillosis due to a mixed infection caused by Aspergillus flavus and A. fumigatus. The implications for this unusual finding are discussed.

Interlaboratory reproducibility of a microsatellite-based typing assay for Aspergillus fumigatus through the use of allelic ladders: proof of concept

An interlaboratory study was performed with the aim of investigating the reproducibility of a multiplex microbial microsatellite-based typing assay for Aspergillus fumigatus in different settings using a variety of experimental and analytical conditions and with teams having variable prior microsatellite typing experience. In order to circumvent problems with exchange of sizing data, allelic ladders are introduced as a straightforward and universally applicable concept for standardization of such typing assays. Allelic ladders consist of mixtures of well-characterized reference fragments to act as reference points for the position in an electrophoretic trace of fragments with established repeat numbers. Five laboratories independently analysed six microsatellite markers in 18 samples that were provided either as DNA or as A. fumigatus conidia. Allelic data were reported as repeat numbers and as sizes in nucleotides. Without the use of allelic ladders, size differences of up to 6.7 nucleotides were observed, resulting in interpretation errors of up to two repeat units. Difficulties in interpretation were related to non-specific amplification products (which were resolved with explanation) and bleed-through of the different fluorescent labels. In contrast, after resolution of technical or interpretive problems, standardization of sizing data by using allelic ladders enabled all participants to produce identical typing data. The use of allelic ladders as a routine part of molecular typing using microsatellite markers provides robust results suitable for interlaboratory comparisons and for deposition in a global typing database.

An aspergilloma caused by Aspergillus flavus

Chronic pulmonary aspergillosis is broad term encompassing chronic cavitary, chronic fibrosing pulmonary aspergillosis and aspergilloma. All affect patients with structural lung diseases and many have subtle genetic immune defects. Almost all cases are caused by Aspergillus fumigatus. Here we report a patient with an aspergilloma which had Aspergillus flavus recovered from a surgical specimen and serum containing detectable precipitating antibody.

Voriconazole plasma monitoring

AIMS

Very little information is available regarding the use of voriconazole drug monitoring in children with invasive fungal infections. The purpose of this study was to report the cases of five paediatric patients treated with voriconazole, in which plasma levels were used to monitor therapy.

METHODS

Five children treated with voriconazole were included in this case series. Voriconazole plasma levels were determined using either a bioassay or liquid chromatography-tandem mass spectrometry.

RESULTS

The patients' ages ranged from 2 to 10 years old (mean 6.2 years). Three patients had acute leukaemia and two had suffered severe burn injuries. Doses administered varied from 3.4 mg/kg every 12 h to 8.1 mg/kg every 8 h. Plasma voriconazole concentrations were unpredictable for these paediatric patients. Subtherapeutic levels were frequently observed, despite progressive increments in dosage. For others, voriconazole levels markedly increased after a small increment in dosage. Phenobarbitone caused important drug interactions with voriconazole for one [corrected] of the patients.

CONCLUSIONS

The dose administered did not correlate with exposure as measured by plasma levels of voriconazole. While the optimal dosage for voriconazole in children is still unknown, drug monitoring seems warranted to ensure adequate exposure, and after dose increments to prevent excessive exposure. Drug interactions significantly altered exposure.

New and emerging treatments for fungal infections

Although several new antifungal drugs have been licensed in the last 5 years, some patients remain difficult to treat. The main reasons for this include intrinsic or acquired antifungal resistance, organ dysfunction preventing the use of some agents and drug interactions. In addition, some drugs penetrate poorly into sanctuary sites including eye and urine, and others are associated with considerable adverse events. Here, we review the preclinical and clinical development progress with four new antifungal agents: isavuconazole, ravuconazole, albaconazole and aminocandin. Isavuconazole and ravuconazole are extremely similar, with a broad spectrum of activity, a very long half-life and large volume of distribution and good in vivo data supporting their efficacy in invasive aspergillosis and candidosis. Both compounds are in early Phase 3 development. Albaconazole has also shown very potent activity against species of Candida, Cryptococcus and Aspergillus. It was well tolerated and effective in women with vaginal candidosis. Aminocandin is an intravenous-only echinocandin with in vivo activity against Candida spp. and Aspergillus spp. Its extended half-life probably permits dosing less frequently than once a day. Overall these new antifungal agents in development offer extended half-lives, possibly reduced drug interaction profiles and good tolerance. Their antifungal spectrum is narrower than posaconazole and probably similar to voriconazole (isavuconazole and ravuconazole) and caspofungin (aminocandin). Licensure and determination of their place in clinical practice requires randomized clinical studies, which are or will be underway.

Polymorphisms in toll-like receptor genes and susceptibility to pulmonary aspergillosis

Toll-like receptors (TLRs) are important components of innate immunity. We investigated the association between polymorphisms in the TLR2, TLR4, and TLR9 genes and susceptibility to noninvasive forms of pulmonary aspergillosis. A significant association was observed between allele G on Asp299Gly (TLR4) and chronic cavitary pulmonary aspergillosis (odds ratio [OR], 3.46; P =.003). Susceptibility to allergic bronchopulmonary aspergillosis was associated with allele C on T-1237C (TLR9) (OR, 2.49; P =. 043). No particular polymorphism was associated with severe asthma with fungal sensitization. These findings reinforce the importance of innate immunity in the pathogenesis of different forms of aspergillosis.

Aspergillus niger causing tracheobronchitis and invasive pulmonary aspergillosis in a lung transplant recipient: case report

A case of invasive aspergillosis caused by Aspergillus niger in a lung transplant recipient is described. The patient presented hyperglycemia starting postoperatively, with other complications such as cytomegalovirus infection. The associated predisposing factors and other implications are discussed. Aspergillus niger seems to be a fungal species of low virulence that requires the presence of a severely immunosuppressed host to cause invasive disease.

Aspergillus flavus: human pathogen, allergen and mycotoxin producer

Aspergillus infections have grown in importance in the last years. However, most of the studies have focused on Aspergillus fumigatus, the most prevalent species in the genus. In certain locales and hospitals, Aspergillus flavus is more common in air than A. fumigatus, for unclear reasons. After A. fumigatus, A. flavus is the second leading cause of invasive aspergillosis and it is the most common cause of superficial infection. Experimental invasive infections in mice show A. flavus to be 100-fold more virulent than A. fumigatus in terms of inoculum required. Particularly common clinical syndromes associated with A. flavus include chronic granulomatous sinusitis, keratitis, cutaneous aspergillosis, wound infections and osteomyelitis following trauma and inoculation. Outbreaks associated with A. flavus appear to be associated with single or closely related strains, in contrast to those associated with A. fumigatus. In addition, A. flavus produces aflatoxins, the most toxic and potent hepatocarcinogenic natural compounds ever characterized. Accurate species identification within Aspergillus flavus complex remains difficult due to overlapping morphological and biochemical characteristics, and much taxonomic and population genetics work is necessary to better understand the species and related species. The flavus complex currently includes 23 species or varieties, including two sexual species, Petromyces alliaceus and P. albertensis. The genome of the highly related Aspergillus oryzae is completed and available; that of A. flavus in the final stages of annotation. Our understanding of A. flavus lags far behind that of A. fumigatus. Studies of the genomics, taxonomy, population genetics, pathogenicity, allergenicity and antifungal susceptibility of A. flavus are all required.

Aspergillus flavus: human pathogen, allergen and mycotoxin producer

Aspergillus infections have grown in importance in the last years. However, most of the studies have focused on Aspergillus fumigatus, the most prevalent species in the genus. In certain locales and hospitals, Aspergillus flavus is more common in air than A. fumigatus, for unclear reasons. After A. fumigatus, A. flavus is the second leading cause of invasive aspergillosis and it is the most common cause of superficial infection. Experimental invasive infections in mice show A. flavus to be 100-fold more virulent than A. fumigatus in terms of inoculum required. Particularly common clinical syndromes associated with A. flavus include chronic granulomatous sinusitis, keratitis, cutaneous aspergillosis, wound infections and osteomyelitis following trauma and inoculation. Outbreaks associated with A. flavus appear to be associated with single or closely related strains, in contrast to those associated with A. fumigatus. In addition, A. flavus produces aflatoxins, the most toxic and potent hepatocarcinogenic natural compounds ever characterized. Accurate species identification within Aspergillus flavus complex remains difficult due to overlapping morphological and biochemical characteristics, and much taxonomic and population genetics work is necessary to better understand the species and related species. The flavus complex currently includes 23 species or varieties, including two sexual species, Petromyces alliaceus and P. albertensis. The genome of the highly related Aspergillus oryzae is completed and available; that of A. flavus in the final stages of annotation. Our understanding of A. flavus lags far behind that of A. fumigatus. Studies of the genomics, taxonomy, population genetics, pathogenicity, allergenicity and antifungal susceptibility of A. flavus are all required.

Flucytosine therapeutic monitoring: 15 years experience from the UK

BACKGROUND

There is uniform consensus that flucytosine blood concentrations should be measured to avoid toxicity and ensure adequate efficacy.

OBJECTIVES AND METHODS

The purpose of this study was to evaluate all flucytosine levels performed in a regional centre in the UK from October 1991 to May 2006. Concentrations were measured by bioassay.

RESULTS

We reviewed 1071 flucytosine levels in 233 patients, including 33 neonates. Overall, only 20.5% of levels were in the expected therapeutic range. Low levels were observed in 40.5%, of which 5.1% were undetectable levels (<12.5 mg/L). High levels occurred in 38.9%, of which 9.9% were considered potentially toxic (>100 mg/L). High flucytosine levels occurred more frequently amongst neonates, which could be related to an immature renal system resulting in drug accumulation.

CONCLUSIONS

Our findings reveal that the vast majority of patients were out of range for flucytosine levels. These data emphasize the importance of monitoring flucytosine levels.

Post-operative aspergillosis

While invasive aspergillosis occurs typically in severely immunocompromised patients, cases of surgical site infection have been reported in immunocompetent individuals. The Medline, LILACS and EMBASE databases were searched for descriptions of cases of post-operative aspergillosis, and references from relevant articles and conference abstracts were reviewed. More than 500 cases of post-operative aspergillosis were found. Cardiac surgery (n = 188), ophthalmological surgery (n > 90) and dental surgery (n > 100) were associated with the majority of cases. Other cases involved wound infections (n = 22), bronchial infections (n = 30), mediastinitis (n = 11), pleural aspergillosis (n = 1), infections following orthopaedic surgery (n = 42), vascular prosthetic surgery (n = 22), breast surgery (n = 5), abdominal surgery (n = 10) and neurosurgery (n = 25). In most patients, the source was presumed to be airborne infection during the surgical procedure. Prevention of these infections requires special care of the ventilation system in the operating room. Successful treatment requires rapid diagnosis, surgical debridement and antifungal therapy, often with voriconazole. In order to improve the outcome, better diagnostic methods are needed, particularly for cases of endocarditis and aortitis.

Candida guilliermondii as the aetiology of candidosis

Candida guilliermondii is one of the components of human microbiota. This yeast has been infrequently associated with human infections, which may be related to its low pathogenicity. The aim of this study was to provide clinical and epidemiological data for patients infected with C. guilliermondii at Santa Casa Complexo Hospitalar, Brazil. From October 1997 to October 2003, C. guilliermondii was isolated from clinical samples from 11 patients. Three patients were excluded because the isolation of the yeast represented colonisation. Specimens from the eight patients included in the study corresponded to blood (n = 5), ascitis fluid (n = 2), and oesophagus biopsy (n = 1). Three patients (37.5%) had major immunosuppressed conditions, including solid organ transplantation, AIDS, and leukaemia. Previous use of antibiotics occurred in 87.5%. Main invasive medical procedures were central venous catheter (50.0%), abdominal surgery (25.0%), and peritoneal dialysis (50.0%). No susceptibility data was obtained. Although risk factors for candidaemia were similar amongst patients infected by with C. guilliermondii or other Candida species, mortality associated with C. guilliermondii was significantly lower.

Candidaemia and cancer: patients are not all the same

Background

Most of the studies about invasive Candida infections in cancer patients have focused on haematological patients. The aim of this study was to provide information about risk factors for candidaemia in patients with solid tumours.

Methods

Retrospective cohort study. During a 9-year period (1995–2003) we reviewed all cases of candidaemia that affected cancer patients in Santa Casa Complexo Hospitalar, Brazil.

Results

During the period of study, 210 patients had the diagnosis of candidaemia in our medical centre, and 83 of these patients had cancer (39.5%). The majority of patients with cancer had solid tumours (77.1%), mostly in the alimentary tract. Most of solid cancers were non-metastatic (71.9%). Major diagnoses in patients with haematological neoplasia were acute leukaemia (n = 13), high grade non-Hodgkin lymphoma (n = 5) and Hodgkin's disease (n = 1). Non-Candida albicans species caused 57.8% of the episodes of candidaemia in patients with cancer, mainly in patients with haematological malignancies (p = 0.034). Neutropenia and treatment with corticosteroids were more frequent in the haematological group, in comparison with patients with solid tumours. Only 22.2% of patients with solid tumours were neutropenic before candidaemia. Nonetheless, the presence of ileus and the use of anaerobicides were independent risk factors for candidaemia in patients with solid cancers. The overall mortality in cancer patients with candidaemia was 49.4%. We then compared 2 groups of adult patients with candidaemia. The first was composed of non-neutropenic patients with solid tumours, and the second group included patients without cancer. We found that central venous catheters and gastrointestinal surgery were independently associated with candidaemia in patients with solid tumour.

Conclusion

Cancer patients with candidaemia seem to have very different predisposing factors to acquire the infection when stratified according to baseline diseases. This study provides some useful clinical information regarding risk for candidaemia in patients with solid tumours.

A 9-year Study Comparing Risk Factors and the Outcome of Paediatric and Adults with Nosocomial Candidaemia

Although there are numerous studies of candidaemia in adults, data on paediatrics are still limited. The aim of this study was to compare risk factors, aetiology, therapy, and the outcome of nosocomial candidaemia among paediatric and adult patients in a large Brazilian tertiary hospital (1995-2003). During this period, 78 paediatrics and 113 adults were studied. Species other than Candida albicans caused 78.2% of episodes of candidaemia in paediatrics. Compared to adults, paediatrics received more frequently broad-spectrum antibiotics, vasopressors, blood transfusions, arterial catheter, chest tube, cardiothoracic surgery, mechanical ventilation, and parenteral nutrition. Candidaemia caused by Candida parapsilosis was more common in paediatrics, as was the isolation of Candida spp. from catheters. Amphotericin B treatment was more common in paediatrics. Mortality rate was higher in adults than in paediatrics with nosocomial candidaemia. We reinforce the necessity of continuous epidemiologic surveillance to follow the dynamics of candidaemia.

Risk factors and outcome for nosocomial breakthrough candidaemia

OBJECTIVES

To describe all cases of nosocomial candidaemia that occurred in patients in use of anti-fungals.

METHODS

Retrospective cohort study (1995-2003). Breakthrough candidaemia was defined as the occurrence of candidaemia in a patient receiving at least 3 days of systemic anti-fungal therapy. Patients with breakthrough candidaemia were compared to patients with non-breakthrough candidaemia.

RESULTS

During the period of study, 20 patients had breakthrough candidaemia, and 40% of them had cancer. While most of these episodes occurred with amphotericin B, some patients received low-dose regimens of fluconazole or ketoconazole in association with ranitidine. Non-Candida albicans species caused 75% of these infections, mainly Candida parapsilosis (30%). When compared to controls (n=171), the breakthrough group had more frequently mucositis, longer stay in the intensive care unit, and longer periods of hyperalimentation, mechanical ventilation, urinary catheter and broad-spectrum antibiotics. Candida isolation from sites other than blood occurred more frequently in the breakthrough group. Mortality rate and Candida species distribution were similar among groups.

CONCLUSIONS

C. parapsilosis was the main aetiology of breakthrough candidaemia. Common risk factors included mucositis, isolation of Candida from sites other than blood, use of broad-spectrum antibiotics, and invasive medical procedures. No difference in the mortality rate was observed.

A comparative study of risk factors and outcome among outpatient-acquired and nosocomial candidaemia

Candidaemia is perceived as a nosocomial infection. The aim of this study was to describe all cases of candidaemia that occurred in the outpatient setting, and to compare risk factors and outcome among patients with outpatient-acquired and nosocomial candidaemia. During 1995 and 2003, 210 patients developed candidaemia at our institution, and 9.0% were outpatient acquired. Major underlying diseases were cancer (47.4%) and chronic renal failure (36.8%). Most occurred within 24 h of hospitalization (63.2%), and 83.7% were caused by species other than Candida albicans, mainly Candida parapsilosis (36.8%). Candida spp. were isolated from catheters in 21% of cases, and 52.6% of patients had been admitted to hospital in the 60 days preceding candidaemia. Compared with patients with nosocomial candidaemia, chronic renal failure was more frequent in the outpatient group, who were also more commonly exposed to haemodialysis. Ileus, gastrointestinal bleeding, previous bacteraemia, use of proton pump inhibitors, previous stay in the intensive care unit and requirement for antibiotics, blood transfusion, vasopressors and invasive medical procedures were more frequent in the nosocomial group. Overall mortality was high in both groups. Candidaemia must be considered as a potential cause of sepsis in the community, and it is associated with a high mortality rate.

Candidemia in a Brazilian tertiary care hospital: species distribution and antifungal susceptibility patterns

Recent studies have shown differences in the epidemiology of invasive infections caused by Candida species worldwide. In the period comprising August 2002 to August 2003, we performed a study in Santa Casa Complexo Hospitalar, Brazil, to determine Candida species distribution associated with candidemia and their antifungal susceptibility profiles to amphotericin B, fluconazole and itraconazole. Antifungal susceptibility was tested according to the broth microdilution method described in the NCCLS (M27A-2 method). Only one sample from each patient was analyzed (the first isolate). Most of the episodes had been caused by species other than C. albicans (51.6%), including C. parapsilosis (25.8%), C. tropicalis (13.3%), C. glabrata (3.3%), C. krusei (1.7%), and others (7.5%). Dose-dependent susceptibility to itraconazole was observed in 14.2% of strains, and dose-dependent susceptibility to fluconazole was found in 1.6%. Antifungal resistance was not found, probably related to low use of fluconazole. Further epidemiological surveillance is needed.