Correlation between in vitro susceptibility of Scedosporium apiospermum to voriconazole and in vivo outcome of scedosporiosis in guinea pigs

We have evaluated the efficacy of voriconazole (VRC) in a systemic infection by Scedosporium apiospermum in immunodepressed guinea pigs. Animals were infected with two strains; one required a VRC MIC of 0.5 to 1 microg/ml, common for this fungus, and the other required a high MIC (8 microg/ml), unusual in this species. VRC prolonged survival and reduced fungal load in kidney and brain tissues of the animals infected with the first strain but was unable to prolong survival or to reduce fungal load in brain tissue for the latter strain.

Antifungal activities of posaconazole and granulocyte-macrophage colony-stimulating factor ex vivo and in mice with disseminated infection due to Scedosporium prolificans

Invasive infection due to Scedosporium prolificans is characterized by drug resistance and a high rate of mortality. The effects of posaconazole (POS), an investigational antifungal triazole, murine granulocyte-macrophage colony-stimulating factor (GM-CSF), and their combination against S. prolificans were evaluated ex vivo and in a newly developed murine model of disseminated infection due to this organism. When POS was combined with polymorphonuclear leukocytes from untreated or GM-CSF-treated mice (P < 0.01) ex vivo, it had increased activity in terms of the percentage of hyphal damage. Immunocompetent BALB/c mice were infected with 4 x 10(4) conidia of S. prolificans via the lateral tail vein. At 24 h postinfection the mice were treated with GM-CSF (5 microg/kg of body weight/day subcutaneously), POS (50 mg/kg/day by gavage), both agents, or saline only. Half of the brain, lung, liver, and kidney from each animal were cultured; and the other half of each organ was processed for histopathology. The mean survival times were 7.0 +/- 0.3 days for the controls, 7.4 +/- 0.4 days for POS-treated mice, 8.0 +/- 0.3 days for GM-CSF-treated mice (P = 0.08 compared with the results for the controls), and 7.3 +/- 0.3 days for POS-GM-CSF-treated mice. Fungal burdens (determined as the numbers of CFU per gram of tissue) were found in descending orders of magnitude in the kidneys, brains, livers, and lungs. The burdens were significantly reduced in the brains of GM-CSF-treated mice (P < 0.05) and the livers of POS-treated mice (P < 0.05). The numbers of lesions in the organs closely corresponded to the fungal burdens. GM-CSF tended to prolong survival (P = 0.08 compared with the results for the controls). While the combination of POS and GM-CSF showed enhanced activity ex vivo, it did not increase the activities of the two agents against this highly refractory filamentous fungus in mice.

Testicular involvement in disseminated fungal infection by Pseudallescheria boydii

We present an immunocompromised patient with a painless testicular mass. Usually, this mass is suspicious for testicular cancer; however, a fungal abscess from Pseudallescheria boydii was found. The patient eventually died from disseminating infection. This is the first such report of a testicular infection involving P. boydii. Early diagnosis and treatment are paramount because of the poor outcome with disseminated disease.

Pseudoallescheria boydii pneumonia and empyema: a rare complication of heart transplantation cured with voriconazole

Pseudoallescheria boydii pneumonia is a rare occurrence, usually resistant to amphotericin B and other anti-fungal agents. We report a complete response to voriconazole in an immunosuppressed host.

Madura foot: atypical finding and case presentation

Mycetomas are chronic, subcutaneous infections characterized by a clinical triad of chronic induration, draining sinuses, and discharge of granules. The granules are composed of colonies of either actinomycotic bacteria or eumycotic fungi. The infection develops after traumatic inoculation with contaminated soil and progresses to adjacent tissues or bone. The foot, hand, and lower-leg regions are the most commonly affected areas. Treatment can be difficult and includes surgical debridement with prolonged antibiotic or antifungal treatment. Mycetomas are primarily found in tropical and subtropical areas of the world and are relatively rare in the United States. A case of indigenously obtained actinomycoses that was successfully treated with surgical resection and long-term antibiotic therapy is presented. This case is unique because of the rarity of contracting this type of infection in the United States. Mycetomas have been reported in southern states, but there are no reported cases of obtaining this pathogen in Michigan. This case stresses the need for clinical suspicion of this rare dermatosis, especially considering the increase in immigration to the United States.

Interferon-gamma and colony-stimulating factors as adjuvant therapy for refractory fungal infections in children

A human immunodeficiency virus-infected boy with Scedosporium apiospermum otomastoiditis and a girl with diabetes mellitus and Mucor sinusitis and orbital cellulitis had life-threatening disease progression despite antifungal treatment. Interferon-gamma and granulocyte-macrophage or granulocyte colony-stimulating factor were added, with good functional outcome in both children. Adjunctive therapy with interferon-gamma, granulocyte-macrophage colony-stimulating factor and granulocyte colony-stimulating factor can be considered for refractory invasive fungal infections.

Case report: Nocardia asteroides mycetoma

Primary cutaneous infections with Nocardia asteroides are rare and have been reported in immunocompromised patients. Herein, we report a case of primary cutaneous Nocardia asteroides mycetoma of the skin in an immunocompetent individual. The infection was treated successfully with trimethoprim-sulfamethoxazole. Because a prolonged incubation time is required for the cultures and since additional biochemical tests are necessary for identification of this species, the clinician should alert the microbiology laboratory when such an infection is suspected clinically.

New options for the treatment of invasive fungal infections

Fungal infections continue to plague patients undergoing treatment of malignancies. In fact, the incidence as well as the types of fungal species causing serious invasive fungal infections is increasing. Candida infections have become the fourth leading cause of nosocomial blood stream infections. Moreover, in addition to Aspergillus, non-Aspergillus species have emerged as etiologic agents of mold infections in cancer patients. Recently, there have been new and much needed re-enforcements to the antifungal armamentarium. These include the broader triazole antifungal agents that are in clinical trials (posaconazole) or have been recently approved (voriconazole) and the echinocandins, a new antifungal class of which the first approved agent caspofungin is now available. We review the clinical data, side effects, drug interactions, and unique spectrum of activity of these newer antifungal agents against both Candida and clinically relevant mold species.

Cushing's syndrome due to interaction between inhaled corticosteroids and itraconazole

OBJECTIVE

To report a case of an interaction between inhaled corticosteroids and itraconazole causing iatrogenic Cushing's syndrome and provide a review of the relevant literature.

CASE SUMMARY

A 70-year-old white woman on long-term treatment with high-dose inhaled corticosteroids for asthma was diagnosed as having Scedosporium apiospermum infection of the skin and subcutaneous tissues. As a result, she was treated with itraconazole for 2 months. She subsequently developed Cushing's syndrome due to a probable cytochrome P450-mediated interaction between itraconazole and budesonide. She also had secondary adrenal insufficiency requiring prolonged treatment with replacement hydrocortisone.

DISCUSSION

Budesonide is a potent glucocorticoid that is metabolized in the liver by the CYP3A4 isoenzyme to inactive metabolites. Itraconazole is a potent cytochrome P450 inhibitor. It can inhibit the metabolism of oral or inhaled corticosteroids, producing cortisol excess leading to Cushing's syndrome and adrenal insufficiency. An assessment of causality indicated a possible adverse interaction between itraconazole and budesonide.

CONCLUSIONS

The combination of itraconazole and inhaled corticosteroids is increasingly being used to treat conditions such as allergic bronchopulmonary aspergillosis. Clinicians need to be aware of the potential for an interaction between such a combination.

Infection of the CNS by Scedosporium apiospermum after near drowning. Report of a fatal case and analysis of its confounding factors

This report describes a fatal case of central nervous system pseudallescheriasis. A 32 year old white man presented with headache and meningismus 15 days after nearly drowning in a swine sewage reservoir. Computerised tomography and magnetic resonance imaging of the head revealed multiple brain granulomata, which vanished when steroid and broad spectrum antimicrobial and antifungal agents, in addition to dexamethasone, were started. Cerebrospinal fluid analysis disclosed a neutrophilic meningitis. Treatment with antibiotics and amphotericin B, together with fluconazole and later itraconazole, was ineffective. Miconazole was added through an Ommaya reservoir, but was insufficient to halt the infection. Pseudallescheria boydii was finally isolated and identified in cerebrospinal fluid cultures, a few days before death, three and a half months after the symptoms began. Diagnosis was delayed because of a reduction in the lesions after partial treatment, which prevented a stereotactic biopsy. Physicians should be aware of this condition, and provide prompt stereotactic biopsy. Confirmed cases should perhaps be treated with voriconazole, probably the most effective, currently available treatment for this agent.

Mycetoma: a thorn in the flesh

Mycetoma is a chronic, granulomatous, subcutaneous, inflammatory disease caused by true fungi (eumycetoma) or filamentous bacteria (actinomycetoma). It occurs in the mycetoma belt stretching between the latitudes of 15 degrees South and 30 degrees North and is endemic in relatively arid areas. The organisms are present in the soil and may enter the subcutaneous tissue by traumatic inoculation. Mycetoma commonly affects adults aged 20 to 40 years, predominantly males. The foot is most commonly affected. Both forms of mycetoma present as a progressive, subcutaneous swelling, although actinomycetoma has a more rapid course. Multiple nodules develop which may suppurate and drain through sinuses, discharging grains during the active phase of the disease. Diagnosis may involve radiology, ultrasonic imaging, cytology, culture, histology or immunodiagnosis. Actinomycetoma is amenable to treatment by antibiotics, preferably by combined drug therapy for long periods. Eumycetoma is usually treated by aggressive surgical excision combined with medical treatment.

Voriconazole: new preparation. Invasive aspergillosis: benefits to be confirmed

(1) Amphotericin B is the antifungal drug of choice for the treatment of invasive aspergillosis, severe candidiasis and Fusarium infection. Voriconazole is an antifungal azole sold in France for oral and intravenous treatment of these infections. (2) In 391 patients with established or probable invasive aspergillosis, combined analysis of two trials comparing voriconazole (intravenously then orally) with conventional amphotericin (intravenously) showed that the 12-week survival rate was significantly higher with voriconazole (70.8% versus 57.9%). Unfortunately, these results are undermined by methodological flaws such as the lack of blinding, the very different intravenous treatment periods in the two groups, and subsequent oral treatment with different antifungal drugs. Voriconazole has not been compared with liposomal amphotericin B. (3) In the treatment of severe candidiasis, and severe Scedosporium and Fusarium infections, we only have the (favourable) results of non comparative trials in small numbers of patients refractory to other antifungal drugs. (4) The main adverse effects were visual disturbances, elevated hepatic enzyme levels, acute renal failure, and sometimes serious cutaneous reactions. It lengthens the QT interval and can cause torsades de pointes. It inhibits the cytochrome P450 isoenzymes CY3A4, CYP2C9 and CYP2C19, hence a high risk of potentially serious drug interactions. (5) Voriconazole can be given by mouth or by IV infusion, whereas liposomal amphotericin B must be given intravenously. (6) In practice, another more rigorous trial is needed to confirm the favourable results obtained with voriconazole in invasive aspergillosis. Voriconazole is the first-line treatment for severe Scedosporium infections, despite limited experience. It is a last resort for severe candidiasis and severe Fusarium infection.

Pulse therapy with amikacin and dapsone for the treatment of actinomycotic foot: a case report

Actinomycetoma is a chronic disease caused by aerobic actinomycetes and affecting the skin, subcutaneous tissue, and bones. It causes significant morbidity and clinically manifests as abscesses and sinus/fistulae with or without granules. Early diagnosis is based on the color, size, histopathology of the granules; culture and metabolic studies are used for further species differentiation. Although sulfamethoxazole-trimethoprim alone or in combination with dapsone for a variable period of time are used as first line agents for treatment, slow response to the therapy and high relapse rates have led to increasing usage of alternative agents like gentamycin, amikacin and cefotaxime. We report a case of actinomycetoma foot who had complete treatment failure with a sulfamethoxazole-trimethoprim-dapsone combination and was successfully treated with combination therapy of amikacin and dapsone without any side effects.

Two cases of subcutaneous Scedosporium apiospermum infection treated with voriconazole

Scedosporium apiospermum is a mold that is increasingly being recognized as an opportunistic pathogen in immunocompromised patients, and treatment is complicated by intrinsic resistance to several antifungal agents. In our hospital, two cases of S. apiospermum infection occurring within 2 weeks were successfully treated with voriconazole. Since both patients were infected with an uncommon pathogen, a search for a common nosocomial source was performed. As environmental cultures yielded no S. apiospermum, and random amplified polymorphic DNA (RAPD) fingerprinting showed that the patients' strains were genotypically unrelated, we considered a common nosocomial source of S. apiospermum to be unlikely.

Efficacy of albaconazole (UR-9825) in treatment of disseminated Scedosporium prolificans infection in rabbits

There are no effective therapeutics for treating invasive Scedosporium prolificans infections. Doses of 15, 25, and 50 mg/kg of body weight/day for the new triazole albaconazole (ABC) were evaluated in an immunocompetent rabbit model of systemic infection with this mold. Treatments were begun 1 day after challenge and given for 10 days. ABC at any dose was more effective than amphotericin B (AMB) at 0.8 mg/kg/day at clearing S. prolificans from tissue (P < 0.007). The percentages of survival at 25 mg of ABC/kg/day were similar to those obtained with AMB. Rabbits showed 100% survival when they were treated with 50 mg of ABC per kg (P < 0.0001 versus control group), and only this dosage was able to reduce tissue burden significantly in the five organs studied, i.e., spleen, kidneys, liver, lungs, and brain.

Cure of orthopaedic infection with Scedosporium prolificans, using voriconazole plus terbinafine, without the need for radical surgery

Scedosporium prolificans infections of normal hosts usually require extensive debridement and sometimes amputation to effect cure, due to the intrinsic resistance of this species to available antifungal agents. Newer agents have not tested favourably. Variable results are obtained with voriconazole, and 100% resistance is described with echinocandins. Itraconazole and terbinafine has offered synergy against various moulds including S. prolificans. In vivo success is reported with the azole/terbinafine combination in S. apiospermum pulmonary infection and Pythium insidiosum periorbital cellulitis. We report a case of orthopaedic infection in a non-immunocompromised host with S. prolificans, in which the combinations of itraconazole/terbinafine and voriconazole/terbinafine showed synergy in vitro, and success was achieved without radical surgery, using voriconazole and terbinafine.

[Madura's foot (mycetoma)]

Mycetoma is a chronic disorder involving the skin, bones and soft tissues and is characterized by multiple discharge sinuses, nodules and swelling of the affected part. It may be caused by actinomycetes or eumycetes. It most commonly involves the foot but occasionally involve the hands, back or shoulders. We describe a 66-year-old male agricultural worker, hospitalized in Military Hospital of Craiova, for leg amputation caused by the disease evolution without response at treatment that was initiated 20 years ago.

[Mycetomas in central Tunisia]

INTRODUCTION

Mycetomas are inflammatory pseudo-tumors containing fungal or actinomycosic-type grains. They are frequent in tropical and subtropical countries and unknown in Tunisia.

PATIENTS AND METHODS

We conducted a retrospective study of 12 cases of mycetoma registered in the Dermatological department of the university hospital in Sousse (central Tunisia) over a period of 27 years, from 1974 to 2001. The diagnosis was confirmed by anatomopathological and/or mycological examination.

RESULTS

The mean age at the onset was of 49 years and the sex ratio of 1. A notion of a traumatism was reported in two cases and eight patients had various agricultural activities. The mean duration of progression was of eight years. The localization was the foot in 10 cases. The mycetoma was of actinomycosic origin in 10 cases, due to Actinomadura madurae in nine cases, to Nocardia spp in one case and of fungal origin in 2 cases:Pseudoallescheria boydii in one case and Madurella mycetomi in the other. Antibiotic therapy was associated with surgical exeresis in nine cases and amputation in the other two cases.

COMMENTS

Confrontation of our results with those of Tunisian series and a review of the literature, helped to specify the clinico-epidemiological characteristics and progression of mycetoma in Tunisia. These characteristics are: the rareness of the infection, the relative frequency of affection in women, the proximal involvement of the foot, the frequency of agricultural activity and the rareness of traumatic past history, the predominance of the actinomycosic origin due to Actinomadura madurae, and the need to associate surgical exeresis with the medical treatment or amputation in order to stop the progress of the disease.

Activity of posaconazole against Pseudallescheria boydii: in vitro and in vivo assays

Thirty isolates of Pseudallescheria boydii were tested to compare the in vitro activity of posaconazole with those of fluconazole and itraconazole, using NCCLS methods. Posaconazole was evaluated in an immunosuppressed mouse model of disseminated pseudallescheriasis. Posaconazole was more effective than itraconazole and as effective as fluconazole in preventing death and significantly reducing the CFU of P. boydii from tissues.

Scedosporium apiospermum keratitis treated with itraconazole

Mycotic keratitis usually occurs in conjunction with trauma to the cornea. Scedosporium apiospermum, a dematiaceous fungus linked to the teleomorph Pseudallescheria boydii is not a common agent of mycotic keratitis. A 22-year old male patient with mycotic keratitis due to S. apiospermum is presented. In in vitro susceptibility testing, the isolate showed resistance against amphotericin B (minimum inhibitory concentration [MIC] 16 microg ml(-1)) but was susceptible to itraconazole (ITC) and fluconazole with MICs of 0.125 microg ml(-1) and 4 microg ml(-1), respectively. The patient was cured clinically after ITC treatment and surgical intervention. Azoles may be superior for eliminating S. apiospermum from infected ocular sites.

Subcutaneous mycoses

Subcutaneous mycoses include a heterogeneous group of fungal infections that develop at the site of transcutaneous trauma. Infection slowly evolves as the etiologic agent survives and adapts to the adverse host tissue environment. Diagnosis rests on clinical presentation, histopathology, and culture of the etiologic agents. This article considers sporotrichosis, chromoblastomycosis, and mycetoma.

Successful control of disseminated Scedosporium prolificans infection with a combination of voriconazole and terbinafine

Disseminated Scedosporium prolificans infections are almost uniformly fatal because of their resistance to antifungal agents. Recently, synergy between triazoles and terbinafine has been demonstrated against Scedosporium prolificans in vitro. Reported here is a patient who developed disseminated Scedosporium prolificans infection following bone marrow transplantation and who was successfully treated with a combination of voriconazole and terbinafine in addition to aggressive surgical debridement. Antifungal synergy testing and combination therapy should be considered in cases of disseminated infection with Scedosporium prolificans.

Activity of voriconazole against corneal isolates of Scedosporium apiospermum

PURPOSE

To determine the in vitro antifungal activity of voriconazole, a new triazole, compared with other polyene and imidazole antifungal agents against corneal isolates of Scedosporium apiospermum.

METHODS

Macro-broth dilution susceptibility testing was performed on five isolates of S. apiospermum obtained from patients with keratomycosis to determine the minimal inhibitory concentrations (MICs) for amphotericin B, natamycin, ketoconazole, itraconazole, and voriconazole. The use of oral voriconazole in the management of a patient with posttraumatic S. apiospermum keratitis is described.

RESULTS

S. apiospermum is generally resistant to commonly used topical ophthalmic antifungal agents. The MIC of voriconazole was 0.5 microg/mL, a concentration lower than that of other imidazoles.

CONCLUSION

Voriconazole has promising activity against and may prove useful in the management of fungal keratitis.

Cutaneous infection due to Scedosporium apiospermum in an immunosuppressed patient

Scedosporium apiospermum, the anamorphic form of Pseudallescheria boydii, is a filamentous fungus with low inherent virulence. Increasing numbers of cases of this infection have been reported probably related to the rising number of immunosuppressed persons. Apart from mycetoma, cutaneous and subcutaneous infection is rarely encountered in clinical practice. We describe a case of cutaneous infection caused by Scedosporium apiospermum in a subject with rheumatoid arthritis and diabetes mellitus who was submitted to long-term therapy with cyclosporin and corticosteroids. Histopathologic examination of a skin biopsy showed a granulomatous infiltrate with hyaline septate hyphae. Culture of two skin biopsies taken at two different observations of the woman, 3 weeks apart, allowed isolation of Scedosporium apiospermum. Therapy with itraconazole, 400 mg/day, for 3 months was effective in curing the infection.

Breakthrough Scedosporium apiospermum (Pseudallescheria boydii) brain abscess during therapy for invasive pulmonary aspergillosis following high-risk allogeneic hematopoietic stem cell transplantation. Scedosporiasis and recent advances in antifungal therapy

Systemic scedosporiasis due to the anamorph or asexual form Scedosporium apiospermum (Pseudallescheria boydii) has become an important cause of opportunistic mycosis, especially in patients undergoing high-risk hematopoietic stem cell transplantation. We report a case of rapidly progressive cerebellar hyalohyphomycosis due to Scedosporium apiospermum in an allogeneic marrow graft recipient receiving treatment for severe graft-versus-host disease. This fatal breakthrough intracranial abscess, due to amphotericin B-resistant (minimum inhibitory concentration > 16 micro g/ml) mold, developed during the course of systemic antifungal therapy given for multicentric pulmonary aspergillosis. Despite treatment with high-dose Abelcet (10 mg/kg daily), free amphotericin B was not detected in postmortem cerebellar tissue. A broad-spectrum triazole-based agent (voriconazole/UK-109, 496--Vfend), and a novel fungal cell wall inhibitor, an echinocandin/pneumocandin analog (caspofungin/MK-0991--Cancidas), which exhibit excellent in vitro activity against most clinical Pseudallescheria boydii-Scedosporium apiospermum isolates, have recently become available in the United States and may provide much needed treatment options for patients at risk.

[Cutaneous and osteoarticular Scedosporium apiospermum infection]

Scedosporium apiospermum is a widely distributed fungus that can be found in the soil, manure and decaying vegetation. Human infection with this fungus is facilited by immunodepression. A 65-year-old man, who was taking oral methylprednisolone for rheumatoid polyarthritis had for a few months ulcerated or suppurative nodules whose incision discharged a thick honey-colored exudate. An ulceration over the first right metatarsophalangian articulation had left the bone exposed. The treatment for Pseudomonas aeruginosa, initially isolated in the exudate was unsuccessful. Other microbiology samples exhibited Scedosporium apiospermum, without bacteria. The pathogenic nature of the infection was proven on a skin and bone (head of the first metatarsian) biopsy showing numerous branching and septate hyphae. The patient was successfully treated by itraconazole. Scedosporium apiospermum is the cause of a growing number of human infections due to widespread use of immunosuppressors. Skin and lung localizations predominate. Osteoarticular infection is relatively rare, which contributes to the originality of this observation. Treatment is not well defined and essentially combines surgical drainage with antifungals like itraconazole. This emergent fungal infection, which has non specific clinical manifestations, must be considered in immunocompromised patients.

Disseminated Pseudallescheria boydii (Scedosporium apiospermum) infection in a renal transplant patient

Transplant recipients receive a number of immunosuppressive medications that result in an increased risk of infection, including infections with microbes that are normally not pathogenic. We describe a patient with end-stage renal disease who underwent kidney transplantation. Six months postoperatively, he presented with a lesion on his ankle, multiple thigh nodules, and right testicular pain. Biopsy of the ankle lesion demonstrated Pseudallescheria boydii (Scedosporium apiospermum), a common environmental fungus. Following orchiectomy, multiple fungal elements were found that were initially described as Aspergillus species, but later identified as P. boydii. In addition, multiple brain abscesses were found on magnetic resonance imaging. Despite treatment with multiple antifungal medications, the patient died of cardiac dysrhythmia. Current diagnostic and therapeutic alternatives for P. boydii are reviewed.

Case Reports. Infection due to Scedosporium apiospermum in renal transplant recipients: a report of two cases and literature review of central nervous system and cutaneous infections by Pseudallescheria boydii/Sc. apiospermum

Two cases of infections due to Scedosporium apiospermum in renal transplant recipients, one localized in the central nervous system, the other in the skin, are presented, and a literature review of 21 cases of central nervous system and cutaneous infections due to Pseudallescheria boydii/Sc. apiospermum is given.

An immunocompetent patient with primary Scedosporium apiospermum vertebral osteomyelitis

Scedosporium apiospermum, the asexual anamorph of Pseudallescheria boydii, is a ubiquitous saprophytic fungus that usually causes cutaneous/subcutaneous infection but may manifest as an invasive disease, often in immunocompromised hosts. Following an extensive literature review, we think that this case represents the first documented report of a primary infection of the spine in an immunocompetent patient. Despite extensive surgical debridement and itraconazole therapy, the patient died of multisystem organ failure of unknown etiology. Our case and three previously reported cases of P. boydii vertebral osteomyelitis highlight the importance of obtaining repeat cultures in patients with culture-negative vertebral osteomyelitis who fail to adequately respond to empiric standard antibacterial and/or antimycobacterial therapy. Combined surgical debridement and antifungal therapy have been required for eradication of P. boydii spinal infections in two previously reported immunocompromised patients, although the optimal antifungal regimen for this infection has not been established.

Clinical presentation of pulmonary mycetoma in HIV-infected patients

STUDY OBJECTIVE

s: Although pulmonary mycetoma has been well-described in immunocompetent hosts, the only description in HIV-infected patients has been of 10 patients from our institution, from 1992 to 1995. To further investigate the impact of HIV status on the presentation and course of pulmonary mycetoma, we conducted a follow-up study.

DESIGN

Retrospective review of all cases of pulmonary mycetoma at Bellevue Hospital from 1992 to 1999.

SETTING

Patients were evaluated on the inpatient chest service and in the outpatient chest and HIV clinics of Bellevue Hospital in New York City.

PATIENTS

We identified 74 patients with pulmonary mycetoma; 20 of them were HIV-infected (27%).

INTERVENTIONS

The 20 HIV-infected patients were treated with antiretroviral and/or antifungal therapy.

MEASUREMENTS AND RESULTS

Predisposing diseases were pulmonary tuberculosis (TB), Pneumocystis carinii pneumonia (PCP), or both TB and PCP. Seventeen patients had a CD4+ cell count of < 100 cells/ micro L at presentation. Hemoptysis was present in 13 patients, but was massive in only 1 patient. Cough was common. Of the 18 patients for whom follow-up was available, 11 received antifungal treatment and 7 were observed without therapy. Six patients received both antiretroviral and antifungal therapy. Disease progression occurred in 50%. Only five patients exhibited radiographic or clinical improvement. All five were treated with both antiretroviral and antifungal therapy.

CONCLUSIONS

PCP is a risk factor for pulmonary mycetoma in the HIV-infected individual. HIV-infected patients with mycetomas have a significant rate of disease progression, although they rarely have life-threatening hemoptysis. A combination of antifungal and antiretroviral therapy may improve the clinical outcome in HIV-infected patients with pulmonary mycetoma.

Treatment of Scedosporium apiospermum brain abscesses with posaconazole

A 41-year-old man with acute lymphoblastic leukemia developed multiple Scedosporium apiospermum brain abscesses. The infection progressed despite neurosurgical drainage and treatment with itraconazole, amphotericin B, and ketoconazole, but the brain abscesses completely resolved after treatment with posaconazole alone.

Mycetoma of the sole

We report a case of mycetoma of the sole of the foot in a 10-year-old caused by Nocardia brasiliensis. It was treated successfully with a combination of trimethoprim-sulfamethoxazole, dapsone and rifampicin.

Chronic necrotizing pulmonary aspergillosis in pneumoconiosis: clinical and radiologic findings in 10 patients

STUDY OBJECTIVE

To characterize clinical, radiographic, and CT findings of chronic necrotizing pulmonary aspergillosis (CNPA) in patients with pneumoconiosis.

METHODS

We studied 10 patients with pneumoconiosis who were seen at Asahi Rosai Hospital and received a clinical diagnosis of CNPA during a 15-year period, and detailed the long-term clinical and radiologic courses of four cases.

RESULTS

All patients were men, ranging in age from 48 to 77 years (mean, 60.1 years). Their occupational histories included pottery making (n = 9) and coal mining (n = 1). Chest radiographic findings by the International Labor Organization profusion grading system were greater than category 2. All patients were symptomatic, with a productive cough, hemoptysis, and dyspnea. Serum findings were positive for the Aspergillus antibody in seven patients. The radiologic findings consisted of parenchymal infiltrates and cavities mostly containing mycetoma, which generally involved the upper lobes. The disease progressed slowly; in one patient, broad destruction of the lung was observed after > 10 years without antifungal administration. Most of the patients experienced clinical and radiologic improvement after receiving antifungal therapy, by oral, inhaled, or intracavitary administration.

CONCLUSIONS

Chronic persistent or progressive upper-lobe infiltrates and cavities in patients with pneumoconiosis should raise the possibility of CNPA. Early diagnosis and initiation of effective therapy are recommended to achieve a better outcome.

Pulmonary scedosporium infection following lung transplantation

Infectious complications are frequent following lung transplantation. Tracheobronchial aspergillosis is the predominant fungal infection in these patients. Infections with Scedosporium apiospermium (Pseudoallescheria boydii) and Scedosporium prolificans (Scedosporium inflatum) have mainly been described in bone marrow transplant recipients and only occasionally in solid organ transplant recipients. We analysed risk factors, the clinical course and outcome of seven lung transplant recipients who developed pulmonary scedosporium infection. Scedosporium apiospermium was documented in bronchoalveolar lavage (BAL) of all seven and Scedosporium prolificans in the BAL of four of these patients. Scedosporium was detected 9-58 months after transplantation. Five of the seven patients had been treated for several months with itraconazole because of previous detection of aspergillus in BAL. All seven patients with scedosporium infection showed airway problems, including early ischemic airway stenosis in one and bronchiolitis obliterans syndrome in the other six patients. Combined treatment with itraconazole and fluconazole was not able to eradicate scedosporium. Four of the seven patients died with advanced bronchiolitis obliterans 3-35 months after the diagnosis of pulmonary scedosporium infection. Three patients are currently alive 3, 6 and 7 years after transplantation, showing persistent scedosporium infection. In conclusion, pulmonary scedosporium infection was seen in lung transplant recipients with structurally abnormal airways and under long-term therapy with itraconazole. Eradication of scedosporium proved difficult, but under combined treatment with itraconazole and fluconazole this opportunistic infection did not disseminate.

Scedosporium endophthalmitis: two fatal disseminated cases of Scedosporium infection presenting with endophthalmitis

The incidence of disseminated infection with Scedosporium species is increasing in patients with haematological malignancy. Two fatal cases are reported of patients with acute myeloid leukaemia and neutropenia who presented with Scedosporium endophthalmitis. Diagnosis of fungal infection was delayed as blood and vitreous cultures were positive only after 3 days in patient 1 and blood culture was positive at 7 days in patient 2. Despite antifungal therapy with amphotericin B and additional fluconazole in patient 2, both patients died of overwhelming fungal septicaemia. Post-mortem examination of the right globe in patient 1 showed haemorrhagic necrotizing chorioretinitis with numerous fungal hyphae in choroidal vessels, choroid, retina and vitreous. Scedosporium species are often resistant to conventional antifungal therapy including amphotericin B. Diagnosis is difficult and mortality in disseminated infection is high.

Scedosporium apiospermum chorioretinitis

PURPOSE

A case of a 24-year-old immunocompetent woman who developed unilateral Scedosporium apiospermum chorioretinitis and diffuse cervical lymphadenitis 10 years after facial steroid injection is described.

METHODS

The patient was initially treated for the misdiagnosis of tuberculous lymphadenitis. Contemporaneous to the enlargement of her lymph nodes, she experienced gradual loss of vision in her left eye. She subsequently underwent lymph node biopsy.

RESULTS

Histopathologic sections stained with Grocott's methenamine silver showed branched septate hyphae and cultures on Sabouraud's agar yielded Scedosporium apiospermum. The patient received oral itraconazole 200 mg twice daily. Lymphadenitis regressed within a year and chorioretinitis scarred within two years.

CONCLUSION

Scedosporium apiospermum may cause isolated chorioretinitis in an immunocompetent individual years after local surgery or trauma and result in significant visual morbidity. Treatment may require prolonged use of systemic itraconazole.

Septic arthritis due to Scedosporium apiospermum: case report and review

Septic arthritis is a relatively common disease, but reports of septic arthritis caused by fungi are still rare and it is often associated with predisposing factors that reduce cellular immunity (alcoholism, cancer, endogenous or exogenous hypercortisolism, intravenous drug abuse). Articular conditions caused by Scedosporium apiospermum are uncommon. Here we report the case of a 32-year-old immunocompetent male with septic arthritis caused by S. apiospermum and review 12 other cases.

Pseudallescheria: an underdiagnosed fungus?

Pseudallescheria has been identified as one of the "clinically significant emerging mycoses" but has received little attention in the cytology literature. Recognition of this fungus is of particular importance clinically, because unlike most other fungi (including Aspergillus, with which it is most frequently confused), Pseudallescheria is not effectively treated with amphotericin B, the most frequently and often the only antifungal agent administered. Features helpful in the diagnosis of Pseudallescheria in cytologic material are presented.