Successful Treatment of Bilateral Renal Mucormycosis With Isavuconazole: A Case Report

Isolated renal mucormycosis (IRM) is a rare disease with high mortality, more commonly seen in immunocompromised patients. Management has traditionally included antifungal drugs with or without nephrectomy. We present the case of a 34-year-old female with a past medical history of type 1 diabetes mellitus and intravenous heroin use who presented with fever, flank pain, hematuria, and vomiting. She was found to have an oliguric acute kidney injury (AKI) with a serum creatinine (Cr) of 2.5 mg/dL. CT showed bilateral emphysematous pyelonephritis and ureteral cultures grew Rhizopus species. Amphotericin B was started before being switched to isavuconazole due to worsening AKI, and hemodialysis was only required transiently. Rather than the traditional approach to treatment, a conservative approach that preserved kidney function was utilized, and the patient was successfully treated with six months of isavuconazole.

Polymicrobial anaerobic sepsis due to Bacteroides fragilis, Eggerthella lenta, Ruminoccocus gnavus, and Bilophila wadsworthia in a patient with myeloproliferative neoplasm

We report a rare case of polymicrobial anaerobic bacteremia caused by four different gut anaerobes: Bacteroides fragilis, Eggerthella lenta, Bilophila wadsworthia, and Ruminococcus gnavus. Early initiation of appropriate therapy and species identification with matrix assisted laser desorption time-of-flight mass spectrometry (MALDI-TOF MS) resulted in full recovery from the infection. Our case highlights the clinical significance of polymicrobial cultures and the importance of performing anaerobic cultures for blood specimens to ensure proper identification and treatment.

Serological analysis reveals an imbalanced IgG subclass composition associated with COVID-19 disease severity

Coronavirus disease 2019 (COVID-19) is associated with a wide spectrum of disease presentation, ranging from asymptomatic infection to acute respiratory distress syndrome (ARDS). Paradoxically, a direct relationship has been suggested between COVID-19 disease severity and the levels of circulating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific antibodies, including virus-neutralizing titers. A serological analysis of 536 convalescent healthcare workers reveals that SARS-CoV-2-specific and virus-neutralizing antibody levels are elevated in individuals that experience severe disease. The severity-associated increase in SARS-CoV-2-specific antibody is dominated by immunoglobulin G (IgG), with an IgG subclass ratio skewed toward elevated receptor binding domain (RBD)- and S1-specific IgG3. In addition, individuals that experience severe disease show elevated SARS-CoV-2-specific antibody binding to the inflammatory receptor FcɣRIIIa. Based on these correlational studies, we propose that spike-specific IgG subclass utilization may contribute to COVID-19 disease severity through potent Fc-mediated effector functions. These results may have significant implications for SARS-CoV-2 vaccine design and convalescent plasma therapy.

Use of Ceftaroline Fosamil in Osteomyelitis: CAPTURE Study Experience

BACKGROUND

Osteomyelitis is often challenging to treat. This analysis examined the clinical experience of patients with gram-positive osteomyelitis treated with ceftaroline fosamil in the phase 4 Clinical Assessment Program and Teflaro® Utilization Registry (CAPTURE) study.

METHODS

Data including patient demographics, past illnesses, risk factors, disease characteristics, antibiotic use, pathogens isolated, and clinical outcome were collected between September 2013 and February 2015 by review of randomly ordered patient charts from participating sites in the United States. Clinical success was defined as discontinuation of ceftaroline fosamil following clinical cure with no further need for antibiotics or clinical improvement with switch to another antibiotic treatment.

RESULTS

A total of 150 patients with gram-positive osteomyelitis were treated with ceftaroline fosamil. Most patients (117/150; 78.0%) were treated with 600 mg ceftaroline fosamil per dose; 143/150 patients (95.3%) received a dose every 12 h. The majority (89/150 patients; 59.3%) had been previously diagnosed with diabetes mellitus or peripheral arterial disease. Osteomyelitis was associated with hardware in 32/150 patients (21.3%). Methicillin-resistant and methicillin-susceptible Staphylococcus aureus (MRSA; MSSA) were the most commonly isolated pathogens, observed in 93/150 (62.0%) and 21/150 (14.0%) patients, respectively. Clinical success with ceftaroline fosamil therapy was observed in 139/150 (92.7%) patients overall, 81/89 (91.0%) patients with diabetes or peripheral arterial disease, and 18/20 (90.0%) patients who had hardware implanted before ceftaroline fosamil therapy (none had hardware removed during therapy). Patients who received prior antibiotic therapy or ceftaroline fosamil as monotherapy experienced clinical success rates of 93.9% (107/114) and 91% (91/100), respectively. Among patients who received concurrent antibiotic therapy, the clinical success rate was 96.0% (48/50). Patients who were infected with MRSA or MSSA had clinical success rates of 92.5% (86/93) and 100% (21/21), respectively. A total of 2/150 (1.3%) patients discontinued ceftaroline fosamil therapy because of adverse events.

CONCLUSIONS

Clinical success rates with ceftaroline fosamil were high in patients with gram-positive osteomyelitis, including those with diabetes or peripheral arterial disease and those with MRSA or MSSA.

Prevalence and impact of baseline resistance-associated substitutions on the efficacy of ledipasvir/sofosbuvir or simeprevir/sofosbuvir against GT1 HCV infection

Baseline resistance-associated substitutions (RASs) have variable impacts in clinical trials but their prevalence and impact in real-world patients remains unclear. We performed baseline resistance testing using a commercial assay (10% cutoff) for 486 patients treated with LDV/SOF or SMV/SOF, with or without ribavirin, in the multi-center, observational HCV-TARGET cohort. Linkage of RASs was evaluated in selected samples using a novel quantitative single variant sequencing assay. Our results showed that the prevalence of NS3, NS5A, NS5B RASs was 45%, 13%, and 8%, respectively, and 10% of patients harbored RASs in 2 or more drug classes. Baseline LDV RASs in GT1a, TE, and cirrhosis LDV/SOF subgroup was associated with 2–4% lower SVR12 rates. SMV RASs was associated with lower SVR12 rates in GT1a, treatment-experienced, cirrhotics SMV/SOF subgroup. Pooled analysis of all patients with baseline RASs revealed that SVR12 was 100% (19/19) in patients treated for longer than 98 days but was 87% (81/93) in patients treated for shorter than 98 days. These results demonstrate that RASs prevalence and their impact in real world practice are in general agreement with registration trials, and suggest that longer treatment duration may overcome the negative impact of baseline RASs on SVR12 rates in clinical practice.

Deautonomization by singularity confinement: an algebro-geometric justification

The ‘deautonomization’ of an integrable mapping of the plane consists in treating the free parameters in the mapping as functions of the independent variable, the precise expressions of which are to be determined with the help of a suitable criterion for integrability. Standard practice is to use the singularity confinement criterion and to require that singularities be confined at the very first opportunity. An algebro-geometrical analysis will show that confinement at a later stage leads to a non-integrable deautonomized system, thus justifying the standard singularity confinement approach. In particular, it will be shown on some selected examples of discrete Painlevé equations, how their regularization through blow-up yields exactly the same conditions on the parameters in the mapping as the singularity confinement criterion. Moreover, for all these examples, it will be shown that the conditions on the parameters are in fact equivalent to a linear transformation on part of the Picard group, obtained from the blow-up.

Ceftaroline fosamil for treatment of diabetic foot infections: the CAPTURE study experience

BACKGROUND

To ascertain which demographic, clinical, and microbiological factors might affect clinical outcomes of patients with diabetic foot infections, excluding known osteomyelitis, by analysing Clinical Assessment Program and Teflaro® Utilization Registry study data of patients treated with ceftaroline fosamil.

METHODS

At participating study centres, we collected data by randomized selection and chart review, including patient demographics, co-morbidities, infecting pathogens, antibiotic use, surgical interventions, and clinical response. Evaluable patients were those with data sufficient to determine clinical outcome. Clinical success was defined as clinical cure with no use of other antibiotics or clinical improvement with a switch to oral antibiotic therapy at the end of intravenous ceftaroline fosamil treatment.

RESULTS

Among 201 patients (mean age 61.7 years, mean body mass index 33.2 and 57% male patients), 40% had peripheral vascular disease. Prior antibiotic therapy had been given to 161 (80%) of the patients, most commonly with vancomycin and/or piperacillin-tazobactam. Patients received ceftaroline fosamil for mean duration of 6.1 days (range 1-30), as monotherapy in 130 (65%) patients and concurrently with other antibiotics in 71 (35%). Bacterial pathogens were identified in 114 (57%) of the patients; methicillin-resistant Staphylococcus aureus and methicillin-sensitive S. aureus were isolated from 56 (49%) and 28 (25%) of culture-positive patients respectively. Clinical success was noted in 81% of patients and was not significantly associated with co-morbidities, pathogen type, or need for surgical intervention.

CONCLUSIONS

Ceftaroline fosamil treatment of diabetic foot infections was associated with high clinical success, including inpatients with obesity, co-morbidities, or methicillin-resistant Staphylococcus aureus or mixed infections or requiring surgical intervention.

Ceftaroline fosamil for the treatment of community-acquired bacterial pneumonia in the intensive care unit

The Clinical Assessment Program and Teflaro^® Utilization Registry (CAPTURE) is a multicenter study evaluating the clinical use of ceftaroline fosamil in patients with community-acquired bacterial pneumonia (CABP) or acute bacterial skin and skin structure infection. Data were collected between August 2011 and February 2013, from 398 evaluable patients receiving treatment at 33 sites in the USA. This manuscript presents data collected from patients with CABP who received care in an intensive care unit (ICU) or in general medical wards (35% and 64% of evaluable patients, respectively). The majority of ICU and general medical ward patients had underlying comorbidities (78% and 74%, respectively), with structural lung disease being the most common (42% in the ICU and 40% in general medical wards). Patients admitted to the ICU had a longer duration of stay, a longer duration of symptoms before treatment, and a longer duration of ceftaroline fosamil therapy than did general medical ward patients. Most patients treated in the ICU and in general medical wards were given ceftaroline fosamil as second-line therapy (87% and 80%, respectively). The overall rate of clinical success for patients treated with ceftaroline fosamil was 68% in the ICU and 85% in the general medical wards. Clinical success for patients receiving ceftaroline fosamil as a second-line agent was 84% in the ICU and 86% in general medical wards. These findings indicate that ceftaroline fosamil is a viable treatment option for CABP, both in the ICU and in general medical wards.

Contemporary use of ceftaroline fosamil for the treatment of community-acquired bacterial pneumonia: CAPTURE study experience

The Clinical Assessment Program and Teflaro(®) Utilization Registry (CAPTURE) is a multicenter cohort study designed to collect information on the contemporary use of ceftaroline fosamil in the US. Data collected from 398 evaluable patients with community-acquired bacterial pneumonia (CABP) (mean age 64 years) during the first 18 months of the study are presented. Most patients had co-morbidities (76%; primarily structural lung disease), and ≧2 signs and symptoms of CABP (76%). Overall clinical success was 79% which varied little with ceftaroline fosamil usage (monotherapy vs concurrent therapy; first-line vs second-line therapy). Most patients were discharged home (60%) or to another healthcare facility (35%). These data suggest that ceftaroline, in contemporary clinical use, is an effective antibiotic for the treatment of patients with CABP, including those with significant co-morbidities or who required a change of their prior antibiotic therapy.

Microbial degradation of microcystin in Florida's freshwaters

Presence of microcystin (MC), a predominant freshwater algal toxin and a suspected liver carcinogen, in Florida's freshwaters poses serious health threat to humans and aquatic species. Being recalcitrant to conventional physical and chemical water treatment methods, biological methods of MC removal is widely researched. Water samples collected from five sites of Lake Okeechobee (LO) frequently exposed to toxic Microcystis blooms were used as inoculum for enrichment with microcystin LR (MC-LR) supplied as sole C and N source. After 20 days incubation, MC levels were analyzed using high performance liquid chromatography (HPLC). A bacterial consortium consisting of two isolates DC7 and DC8 from the Indian Prairie Canal sample showed over 74% toxin degradation at the end of day 20. Optimal temperature requirement for biodegradation was identified and phosphorus levels did not affect the MC biodegradation. Based on 16S rRNA sequence similarity the isolate DC8 was found to have a match with Microbacterium sp. and the DC7 isolate with Rhizobium gallicum (AY972457).

Breaking Instance-Independent Symmetries In Exact Graph Coloring

Code optimization and high level synthesis can be posed as constraint satisfaction and optimization problems, such as graph coloring used in register allocation. Graph coloring is also used to model more traditional CSPs relevant to AI, such as planning, time-tabling and scheduling. Provably optimal solutions may be desirable for commercial and defense applications. Additionally, for applications such as register allocation and code optimization, naturally-occurring instances of graph coloring are often small and can be solved optimally. A recent wave of improvements in algorithms for Boolean satisfiability (SAT) and 0-1 Integer Linear Programming (ILP) suggests generic problem-reduction methods, rather than problem-specific heuristics, because (1) heuristics may be upset by new constraints, (2) heuristics tend to ignore structure, and (3) many relevant problems are provably inapproximable. Problem reductions often lead to highly symmetric SAT instances, and symmetries are known to slow down SAT solvers. In this work, we compare several avenues for symmetry breaking, in particular when certain kinds of symmetry are present in all generated instances. Our focus on reducing CSPs to SAT allows us to leverage recent dramatic improvement in SAT solvers and automatically benefit from future progress. We can use a variety of black-box SAT solvers without modifying their source code because our symmetry-breaking techniques are static, i.e., we detect symmetries and add symmetry breaking predicates (SBPs) during pre-processing. An important result of our work is that among the types of instance-independent SBPs we studied and their combinations, the simplest and least complete constructions are the most effective. Our experiments also clearly indicate that instance-independent symmetries should mostly be processed together with instance-specific symmetries rather than at the specification level, contrary to what has been suggested in the literature.

Estimation of the macromolecular proton fraction and bound pool T2 in multiple sclerosis

This study used a model for magnetization transfer (MT) to estimate two underlying parameters: the macromolecular proton fraction (f) and the bound pool T2 (T2b) in patients with multiple sclerosis (MS). Sixty patients with clinically definite MS and 27 healthy controls were imaged using: (1) a dual echo fast spin echo sequence, (2) a MT sequence (with ten MT power and offset frequency combinations) and (3) proton density and T1 weighted sequences (for T1 relaxation time estimation). Fourteen normal-appearing white matter (NAWM) regions of interest (ROI) and six normal-appearing gray matter (NAGM) ROIs were outlined in all subjects. Lesions were also contoured in subjects affected by MS. The model was fitted to the data leading to estimates of T2b and f. Results showed that T2b was increased in lesions whereas f was reduced. In NAWM, f was decreased while T2b was only increased in secondary progressive MS. NAWM f correlated modestly with disability. Further studies are needed to investigate the pathological basis of the abnormalities observed.

Another approach to protons with constricted mobility in white matter: pilot studies using wideline and high-resolution NMR spectroscopy

We report a new approach for the identification of an independent method of studying the semi-solid pool of protons, i.e., protons with constrained motion as a result of being bound to lipid and protein matrices. These protons cannot be observed using conventional imaging techniques since their transverse relaxation times are much shorter than the minimum echo times that are currently available on clinical scanners. In this pilot study, in vitro multicomponent transverse relaxation experiments were made on human white matter slices, fixed in formalin (7 normal and 5 with multiple sclerosis). The transverse relaxation decay curves were multiexponential and were decomposed to yield three primary components. The shortest T(2) component that we obtained (a component too short to be seen by in vivo methods) was of the order of microseconds. We hypothesize that this might correspond to the macromolecular pool of lipid protons trapped within the myelin sheaths. To our knowledge, this is the first attempt at extracting this ultra short T(2) component from human white matter. Subsequently, an attempt was made to directly detect the lipid protons in a proton NMR spectrum and, if possible, measure their concentration in some of the tissues, using the technique of magic angle spinning.

Quantitative magnetization transfer mapping of bound protons in multiple sclerosis

Quantitative analysis of magnetization transfer images has the potential to allow a more thorough characterization of the protons, both bound and free, in a tissue by extracting a number of parameters relating to the NMR properties of the protons and their local environment. This work develops previously presented techniques to produce estimates of parameters such as the bound proton fraction, f, and the transverse relaxation time of the bound pool, T(2B), for the whole brain in a clinically acceptable imaging time. This is achieved by limiting the number of data collected (typically to 10); to collect 28 5-mm slices with a reconstructed resolution of 0.94 x 0.94 mm. The protocol takes 82 sec per data point. The fitting technique is assessed against previous work and for fitting failures. Maps and analysis are presented from a group of seven controls and 20 multiple sclerosis patients. The maps show that the parameters are sensitive to tissue-specific differences and can detect pathological change within lesions. Statistically significant differences in parameters such as T(2B) and f are seen between normal-appearing white matter, multiple sclerosis lesions, and control white matter. Whole-brain histograms of these parameters are also presented, showing differences between patients and controls.

Preliminary magnetic resonance study of the macromolecular proton fraction in white matter: a potential marker of myelin?

We report on a new quantitative magnetization transfer (MT) technique that allows for the in vivo estimation of the macromolecular proton fraction (f) and the bound pool T2 relaxation time (T2b), whilst permitting whole brain coverage. In this pilot study, five subjects with multiple sclerosis (MS) and five healthy controls were studied. Both f and T2b were significantly different between MS lesions and normal control white matter (WM). Relationships between f and T1 relaxation time [Spearmans rank correlation coefficient (r(s)) = -0.97, P < 0.001] and f and the magnetization transfer ratio (MTR; r(s) = 0.80, P < 0.001) were observed. Compared with MTR, f and T2b have the potential advantage of relative independence from MT acquisition protocol while offering more pathologically specific information. In particular, f may provide a more direct indication of myelin content in WM.

Precise estimate of fundamental in-vivo MT parameters in human brain in clinically feasible times

A methodology is presented for extracting precise quantitative MT parameters using a magnetisation-prepared spoiled gradient echo sequence. This method, based on a new mathematical model, provides relaxation parameters for human brain in-vitro and in-vivo. The in-vivo parameters have been obtained from three different regions of normal white matter: occipital white matter, frontal white matter and centrum semiovale; two regions of normal grey matter: cerebral cortex and cerebellum, and from five regions with MS lesions. All this has been achieved using MT images collected within a timeframe that is clinically feasible. We hope that this new technique will shed light on the properties and dynamics of water compartments within the brain.

Rapid flow cytometric susceptibility testing of Candida albicans

A rapid flow cytometric assay for in vitro antifungal drug susceptibility testing was developed by adapting the proposed reference method for broth macrodilution testing of yeasts. Membrane permeability changes caused by the antifungal agent were measured by flow cytometry using propidium iodide, a nucleic acid-binding fluorochrome largely excluded by the intact cell membrane. We determined the in vitro susceptibility of 31 Candida albicans isolates and two quality control strains (Candida parapsilosis ATCC 22019 and Candida krusei ATCC 6258) to amphotericin B and fluconazole. Amphotericin B MICs ranged from 0.03 to 2.0 microg/ml, while fluconazole MICs ranged from 0.125 to 128 microg/ml. This method results in clear-cut endpoints that were reproducible. Four-hour incubation was required for fluconazole, whereas a 2-h incubation was sufficient for amphotericin B to provide MICs comparable to the reference macrodilution method developed by the National Committee for Clinical Laboratory Standards Subcommittee on Antifungal Susceptibility Tests. Results of these studies show that flow cytometry provides a rapid and sensitive in vitro method for antifungal susceptibility testing of C. albicans.

Fungal colonization in gastric ulcers

Until now studies on fungal colonization of gastric ulcers were retrospective involving small series of patients. This prospective study of 50 patients with gastric ulcers (25 benign and 25 malignant) revealed colonization by Candida in 17 (34%) cases. There was no significant difference in colonization between benign and malignant ulcers. Follow up revealed no difference in healing of ulcers with or without fungal colonization.

Penicillium species causing onychomycosis

Onychomycosis caused by mould infection is rare. A 40 year old male patient presented with dystrophic finger nails and multiple, erythematous lesions with slightly raised borders and scaling all over the body. The patient was a known diabetic. He did not respond to griseofulvin. Samples from nails and skin scales were cultured. From the nails, Penicillium species and from the skin scales. Trichophyton rubrum were isolated. Ketoconazole therapy (200 mg twice daily x 4 mths) led to complete cure with negative cultures and normalization of nails.

Molds in onychomycosis

BACKGROUND

Onychomycosis is a major cause of nail dystrophy. The causative organisms in onychomycosis are dermatophytes, Candida and molds. A variety of molds have been isolated from nails.

METHODS

Nail scrapings and clippings were collected from 100 cases and inoculated on slants containing SDA with cycloheximide 0.5 mg/mL, chloramphenicol 0.05 mg/mL, and SDA with chloramphenicol 0.05 mg/mL.

RESULTS

The culture positivity rate for molds was 22%. The predominant mold isolates were Aspergillus species (86.4%, Fusarium oxysporum (4.5%), Curvularia species (4.5%) and Penicillium species (4.5%).

CONCLUSION

Primary invasion of nails by molds can cause onychomycosis.

Hemorheologic approach in the treatment of diabetic foot ulcers

Pentoxifylline, a new trisubstituted methylxanthine derivative, is the most well known of a new group of hemorheologic agents. It has been shown to improve hemorheologic abnormalities associated with diabetes and atherosclerosis. The authors examined the role of pentoxifylline in the treatment of diabetic foot ulcers. Forty diabetic patients with foot ulcerations were included in the study, 20 of whom received conventional therapy and 20 received pentoxifylline (400 mg three times a day) in addition. Healing of ulcers after eight weeks of treatment was significantly higher in those on pentoxifylline, and the patients needed less mutilating surgery. Administration of pentoxifylline in addition to conventional therapy was significantly superior in the management of diabetic foot ulcers.

Ultrasound-guided needle aspiration of amoebic liver abscess

This prospective study was carried out on 200 patients with clinically, ultrasonographically and serologically confirmed amoebic liver abscess. The role of ultrasound-guided needle aspiration in addition to medications was evaluated compared to drug treatment alone. Both the groups were monitored clinically and sonographically for up to 6 months after diagnosis. The initial response (after 15 days) was better in the aspirated group (P < 0.05) but resolution of abscess after 6 months were similar. There was a more rapid clinical response in the aspirated group, particularly in those with larger (> 6 cm) abscesses and there were no complications. Percutaneous ultrasound-guided needle aspiration is a safe diagnostic and therapeutic approach which enhances clinical recovery, accelerates resolution, especially in large abscesses, and prevents complications.

Glycemic control and its relationship to diabetic foot ulcers

Glucosylhaemoglobin (HbA1) was estimated in 60 diabetic patients, 30 with foot ulceration and 30 without foot lesions. Peripheral neuropathy and vascular disease were commonly found in the ulcer' group. The mean HbA1 level in diabetics without ulcers was 9.77 +/- 2.34, while the corresponding level in diabetics with ulcers was 14.14 +/- 3.63. The difference in values is statistically highly significant (p less than 0.001) suggesting that foot ulcers are more likely to occur in poorly controlled diabetic patients.