Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group

A case of CNS aspergillosis in a patient with chronic lymphocytic leukemia on first-line ibrutinib therapy

Ibrutinib has revolutionized the treatment of chronic lymphoid malignancies. Despite its success, ibrutinib has been linked with several reports of invasive fungal infections. We present a case of CNS aspergillosis in a CLL patient on first line ibrutinib therapy. We summarize existing case reports and case series of invasive aspergillosis in patients on ibrutinib, the pathogenesis of invasive aspergillosis, and discuss the clinical controversies regarding anti-fungal prophylaxis in this population.

Combination antifungals as an effective means of salvage in paediatric leukaemia patients with invasive fungal infections

Invasive fungal infections (IFIs) are an important cause of morbidity and mortality in paediatric leukaemias. Antifungal combinations to treat these patients are being explored. Fourteen children with leukaemias and IFIs were treated with a combination of antifungal agents at our centre. The first antifungal was amphotericin-B in 13 children and voriconazole in one child. In view of no improvement and clinical deterioration, in nine patients, voriconazole was added as the second antifungal agent and in four, it was caspofungin. All patients completed 4-6 weeks of antifungal therapy. The overall mortality attributable to IFI for the cohort was 4/14 (28%).

Study of Hemolysin Gene "aspHS" and Its Phenotype in Aspergillus Fumigatus

AIM:

The main goal of this study was to analysis the “aspHS” gene and its phenotype in A. fumigatus.

METHODS:

Fifty-three A. fumigatus strains, including environmental, clinical and reference isolates, were used in this research. PCR was carried out based on Asp-hemolysin gene sequence. Two restriction enzymes TagI and NcoI were employed for digestion of PCR products.

RESULTS:

PCR products of 180 and 450 bp were generated for all A. fumigatus isolates. Digestion of the aspHS gene 180 bp amplicons with TagI and 450 bp amplicons with TagI and NcoI produced the expected bands for most isolates. Hemolysin production of A. fumigatus isolates was evaluated on sheep blood agar (SBA).

CONCLUSION:

In conclusion, our results provide evidence hemolysin activity and analysis of aspHS gene of A. fumigatus. These data may be useful in early diagnosis of A. fumigatus infections.

Phenotypic profile of pulmonary aspergillosis and associated cellular immunity among people living with human immunodeficiency virus in Maiduguri, Nigeria

OBJECTIVE

Aspergillus causes many forms of pulmonary infectious diseases ranging from colonization (noninvasive) to invasive aspergillosis. This largely depends on the underlying host's lung health and immune status. Pulmonary aspergillosis (PA), especially the invasive form, occurs as opportunistic to human immunodeficiency virus (HIV) as a result of cluster of differentiation (CD)4+ lymphopenia. The majority of patients with comorbid HIV and aspergillosis go undiagnosed. This study aimed to isolate, identify the etiologies, and determine the prevalence of PA among HIV-infected persons with a productive cough (at least <2 weeks) at the HIV Clinics of the University of Maiduguri Teaching Hospital, Nigeria.

MATERIALS AND METHODS

After ethical approval, three consecutive early morning sputum samples were collected from patients with negative tuberculosis results. The samples were individually inoculated onto Sabouraud dextrose agar supplemented with chloramphenicol and cycloheximide in duplicate for 7 days at 37°C and 25°C, respectively. The fungal isolates were examined morphologically and microscopically and identified using the standard biochemical reagents. CD4+ cell counts were performed using flow cytometry. Self-administered questionnaires were used to assess the patients data. All patients were antiretroviral naïve.

RESULTS

The prevalence of PA was 12.7% in these 150 patients. Of the 19 fungal culture-positive individuals, Aspergillus fumigatus accounted for the highest proportion of the isolates (8, 42.1%) followed by Aspergillus niger (5, 26.3%), Aspergillus flavus (4, 21.1%), and Aspergillus terreus (2, 10.5%). Based on the assessment of functionality of cellular immunity, HIV participants who were negative for PA (131/150) had significantly higher mean ± standard deviation CD4 T-cell counts (245.65 ± 178.32 cells/mL) than those with aspergillosis (126.13 ± 105.27 cells/mL) (P = 0.0051). PA was relatively highest among patients with CD4+ cell counts <200 cells/mL (12. 34.3%) followed by those with CD4+ cell counts between 200 and 350 cells/mL (5, 9.6%) and least among those with CD4+ cell counts >350 cells/mL (2, 3.2%). The Chi-square test showed a significant association between the prevalence of PA and the CD4+ cell count, age, and gender (P < 0.05) but not with occupation or education level (P > 0.05).

CONCLUSION

The findings from this study indicate that Aspergillus spp. is a significant etiology of acute productive cough in people living with HIV and this is related to the CD4+ cell count of coinfected persons.

Effect of amphotericin B and voriconazole on the outgrowth of conidia of Aspergillus fumigatus followed by time-lapse microscopy

Studies of morphological measurements from the outgrowth of cells to a network of hyphae have been extended from Candida albicans (Nagy et al. in Appl Microbiol Biotechnol 98(11):5185-5194. https://doi.org/10.1007/s00253-014-5696-5 , 2014) to invasive conidiospores of Aspergillus fumigatus upon treatment with antifungal agents. The understanding of mycelial processes is important to optimize industrial processes such as fermentation and contributes to the fight against pathogenic fungi. This brief study combines TLS with digital image analysis. The TLS system was adapted to get information related to the adherence and growth dynamics of filamentous fungi. This approach was used earlier to distinguish among subphases of bacterial and fungal infections of mammal cells by detecting Mycoplasma infection in cell cultures causing serious damages in cell cultures. We describe changes in adherence, germination of spores, and hyphal growth of A. fumigatus, taking place in the absence and presence of amphotericin B (AMB) and voriconazole (VRC). These growth parameters were measured by TLS in CO₂ incubator under physiological Photomicrography by TLS and extended for a longer period of time up to several weeks combined with image analysis represents a comfortable and reliable means to characterize the growth dynamism of A. fumigatus. The most important observation of medical importance related to the pathomechanism of VRC was that it did not adhere to conidiospores, i.e. that it did not contribute to the attachment of spores to the growth surface, and did not prevent germination but delayed hypha protrusion and elongation. In contrast AMB adhered to conidia, inhibited germination, hypha elongation and branching. It was concluded that AMB was efficient against the therapy of growth but not against the prevention of fungal infection.

Preparation, structural characterization, thermal properties and antifungal activity of alginate-CuO bionanocomposite

In this study, the antifungal activity rate of alginate-CuO bionanocomposite was assessed against Aspergillus niger using colony forming units (CFU) and disc diffusion methods. Employing the Taguchi method, nine experiments were designed for the synthesis of alginate-CuO nanocomposite with the highest antifungal activity. The nanocomposite synthesized under the conditions of experiment 5 (4 mg/mL CuO nanoparticles and 1 mg/mL alginate biopolymer with stirring time of 90 min) showed the greatest inhibition rate on fungal growth (83.17%). In the optimum conditions for the synthesis of alginate-CuO nanocomposite with the highest antifungal activity the second level of CuO NPs (14.14%), alginate biopolymer (8.16%) and stirring time (5.63%) showed the best improvement performance on inhibiting the fungal growth. The results of ultraviolet-visible spectroscopy (UV-vis), transmission electron microscopy (TEM) and X-ray powder diffraction (XRD) confirmed the formation of alginate-CuO nanocomposite. Thermogravimetric analysis (TGA) and differential thermal analysis (DTA) indicated that the thermal stability of alginate biopolymer and CuO nanoparticles were improved by the formation of the nanocomposite. Due to the favorable properties of alginate-CuO nanocomposite, its antifungal feature can be used in various biomedical fields.

Diagnostic role of polymerase chain reaction in bronchoalveolar lavage fluid for invasive pulmonary aspergillosis in immunocompromised patients - A retrospective cohort study

BACKGROUND

This study aimed to evaluate the diagnostic role of PCR detection of Aspergillus DNA in the broncho-alveolar lavage (BAL) fluid in a large cohort of patients suspected to have invasive pulmonary aspergillosis (IPA).

METHODS

Consecutive immunocompromised patients who underwent bronchoscopy with BAL sampling and PCR detection of Aspergillus DNA for the diagnosis of pulmonary infiltrates were included in the study. Galactomannan (GM) antigen testing in BAL and serum and BAL fungal culture were also performed. Patients were classified as having IPA (proven/probable/possible) or no-IPA according to the EORTC/MSG diagnostic criteria.

RESULTS

During 12 years (2005-2016), 1248 bronchoscopies were performed for 1072 patients. 77% had hematological malignancy, of them 40% had AML and 35.6% underwent HSCT. IPA was diagnosed in 531 patients (42.5%), 7-proven, 280-probable and 244-possible. PCR was positive in 266 cases, of them 213 had IPA, indicating a true positive rate of 80% (213/266) and a false positive rate of 20% (53/266). These results establish the diagnostic performance of PCR to have sensitivity of 40%, specificity of 93%, PPV- 80% and NPV-68%. Of 244 patients with possible IPA, 80 had positive PCR. Including PCR in the diagnostic criteria would move 80 cases from the possible group to the probable one. A combination of positive PCR and/or BAL-GM increases sensitivity to 74%, while positivity of both tests elevates PPV to 99.4%.

CONCLUSIONS

Inclusion PCR for the detection of Aspergillus-DNA in BAL in the mycological criteria of the EORTC/MSG definitions increases the rate and the certainty of IPA diagnosis.

Characterisation of novel-cell-wall LysM-domain proteins LdpA and LdpB from the human pathogenic fungus Aspergillus fumigatus

Aspergillus fumigatus, a filamentous fungus that is ubiquitous in the environment, causes several human pulmonary disorders, including chronic and acute invasive infections and allergic diseases. Lysin motif (LysM) is a small protein domain that binds chitin, a major component of fungal cell wall polysaccharides. Several secreted LysM-domain proteins without catalytic function (LysM effectors) have been identified. They act as virulence factors in plant pathogenic fungi by preventing the immune response induced by chitin; however, LysM proteins in mammalian pathogenic fungi remain largely unexplored. We describe two novel LysM-domain proteins, LdpA and LdpB, in A. fumigatus. Functional analyses of single and double knockouts revealed no significant effects on cell wall chitin content, cell wall integrity, fungal morphology and fungal growth. Fluorescent signals from LdpA-green fluorescent protein (GFP) and LdpB-GFP were observed in cell wall and extracellular matrix. In a mouse model of invasive pulmonary aspergillosis, survival did not differ between ΔldpA/B and wild-type infection; however, further studies are required to reveal their functions in fungal−host interactions.

Silkworm as an experimental animal for research on fungal infections

Silkworm, Bombyx mori, has various advantages as an experimental animal, such as the low cost for rearing and fewer ethical problems. Models utilizing silkworms of infection with pathogenic bacteria have been established for identification of genes encoding virulence factors by large-scale in vivo screening. In this review, we describe recent progress in the study of silkworm infection models for elucidating the mechanisms of fungi infection. Silkworm infection models have been established for Candida albicans, Candida tropicalis, Candida glabrata and Cryptococcus neoformans, which are yeast type fungi, and Aspergillus fumigatus, Arthroderma vanbreuseghemii, Arthroderma benhamiae, Microsporum canis, Trichophyton rubrum, and Rhizopus oryzae, which are filamentous fungi. Novel genes encoding virulence factors in C. albicans and C. glabrata have been identified by using the silkworm infection models. We here outline the benefits of using silkworm infection models and a strategy for identifying the genes responsible for pathogenicity of microorganisms such as fungi. © 2019 The Authors. Microbiology and Immunology Published by The Societies and John Wiley & Sons Australia, Ltd.

Skin Infections

Cutaneous infections are common in immunocompromised patients. Neutropenia predisposes patients to fungal, bacterial and viral infections. Antibacterial antifungal and antiviral prophylaxis have caused a significant reduction in some of these infections.

There are two main types of cutaneous infections : primary cutaneous infections and cutaneous manifestations of a disseminated infection. In the latter, skin lesions may be the window to disseminated bloodstream infection and the first and only evidence of a disseminated life threatening infection.

The diagnosis may be at your fingertips; therefore a thorough skin exam is the clue. However, it’s also important to know the characteristic lesions associated with different infections. It will help expedite diagnosis so appropriate treatment is initiated promptly in neutropenic patients, which can be lifesaving.

In a retrospective study of 43 neutropenic febrile patients with cutaneous lesions, fungal infections were the most frequent, and nodular lesions on the lower extremities were the most prevalent (Naorungroj and Aiempanakit, J Am Acad Dermatol 74:AB166, 2016).

Skin biopsy for pathological study and culture remains the gold standard and should be obtained early to confirm the suspected diagnosis. In these immunocompromised patients the inflammatory response is altered by either the primary disease or its treatment. Therefore, routine pathogens may present in an atypical fashion, with diminished or absent induration, erythema, or pustulation in response to bacterial resulting cutaneous infection without typical cellulitis (Urabe, Clin Infect Dis 39:S53–S55, 2004). Skin lesions are evaluated not only by morphology, but also in the context of the clinical setting and biopsy result. The skin biopsy is inexpensive, relatively noninvasive and without contraindication, and may avoid the need for more invasive procedures such an open lung biopsy (Grossman, et al., Cutaneous manifestations of infection in the immunocompromised host. Springer Science+Business Media, LLC, New York, 2012).

In addition to antimicrobial therapy, surgery should not be postponed in the face of progressive skin and soft tissue infection in this population (Brzozowski and Ross, J Hand Surg Br 22:679–680, 1997).

Respiratory Tract Infections: Sinusitis, Bronchitis, and Pneumonia

Solid organ and hematopoietic stem cell transplant recipients are at increased risk of upper and lower respiratory tract infections. While these infections are frequently encountered in the general population, the spectrum of their clinical presentation including morbidity and mortality is increased in patients undergoing transplantation procedures. Impaired innate and adaptive immunity, potential anatomical abnormalities resulting from extensive surgical procedures, presences of indwelling medical devices, and increased healthcare exposure put transplant recipients at particularly high risk for respiratory tract disease. Infections of the respiratory tract can be divided into those affecting the paranasal sinuses, the upper airways such as bronchitis and tracheobronchitis, and the lower airways like pneumonia. Each of these clinical syndromes can further be classified based on their chronicity, acute vs. chronic; their setting, community vs. nosocomial; and the etiology such as bacteria, viruses, fungi, and rarely parasites. It is also important to realize that such immunologically vulnerable patients are at risk for polymicrobial infection that may present concurrently or in a sequential, consecutive fashion. This chapter reviews the common respiratory tract infections affecting transplant recipients with particular attention directed toward epidemiological risk factors, clinical presentations, diagnostic strategies, and common pathogens. Specific causes of opportunistic pneumonias are also reviewed.

A Case Of Cavernous Sinus Syndrome and Mutifocal Cerebral Infarction Related To Mucormycosis Of Sphenoid Sinus

A 54-year-old man, suffering from severe headache and ophthalmoplegia after undergoing endoscopic sinus surgery was referred to a tertiary hospital. Computed tomography (CT) revealed soft tissue density lesions in the left sphenoid sinus. The internal carotid artery was shown to be occluded in brain magnetic resonance imaging (MRI) scans without any other cerebral lesion. Endoscopic view of left nasal cavity shows whitish hyphae in the ethmoid and the sphenoid sinuses. We diagnosed him with cavernous sinus syndrome caused by mucormycosis and conducted endoscopic sinus surgery to remove remaining lesions and decompress orbit and optic nerves. After the revision surgery the patient's headache and ophthalmoplegia were improved. However, multifocal cerebral infarctions were newly discovered in a postoperative CT scan. We experienced a case of mucormycosis of sphenoid sinus resulting in occlusion of internal carotid artery and multifocal cerebral infarction, and report it with a brief review of these disease entities.

Inflammatory and infectious manifestations of immunodeficiency in the gastrointestinal tract

Immune compromise may result from genetic abnormalities, HIV/AIDS, or consequences of therapy for neoplastic and autoimmune diseases. Many immunocompromised patients develop severe gastrointestinal symptoms, particularly diarrhea, accompanied by non-specific or mild endoscopic abnormalities; mucosal biopsy with pathologic interpretation has a major role in the diagnosis and management of these patients. Immunocompromised individuals are at risk for all the diseases that affect those with a healthy immune system, but they are also prone to other illnesses that rarely affect immunocompetent patients. This review discusses the gastrointestinal manifestations of primary and acquired immunodeficiency, chemotherapy-related injury, and infections that show a predilection for immunocompromised patients. Key histologic features and relevant differential diagnoses are emphasized.

Triazole resistance surveillance in Aspergillus fumigatus

Triazole resistance is an increasing concern in the opportunistic mold Aspergillus fumigatus. Resistance can develop through exposure to azole compounds during azole therapy or in the environment. Resistance mutations are commonly found in the Cyp51A-gene, although other known and unknown resistance mechanisms may be present. Surveillance studies show triazole resistance in six continents, although the presence of resistance remains unknown in many countries. In most countries, resistance mutations associated with the environment dominate, but it remains unclear if these resistance traits predominately migrate or arise locally. Patients with triazole-resistant aspergillus disease may fail to antifungal therapy, but only a limited number of cohort studies have been performed that show conflicting results. Treatment failure might be due to diagnostic delay or due to the limited number of alternative treatment options. The ISHAM/ECMM Aspergillus Resistance Surveillance working group was set up to facilitate surveillance studies and stimulate international collaborations. Important aims are to determine the resistance epidemiology in countries where this information is currently lacking, to gain more insight in the clinical implications of triazole resistance through a registry and to unify nomenclature through consensus definitions.

Intracranial Fungal Infection After Solid-Organ Transplant

Neurologic complications after solid-organ transplant reveal a great spectrum of pathologies. Intracranial hemorrhages, cerebral ischemic lesions, infarctions, lymphoproliferative disorders, and infections, including aspergillosis, have been observed after liver transplant. Fungi constitute nearly 5% of all central nervous system infections, mainly occurring in immunocompromised patients. The most common causative agent is Aspergillus species. It presents either as maxillary sinusitis or pulmonary infection. Brain involvement of Aspergillus carries a high rate of mortality. Aspergillosis presents in the forms of meningitis, mycotic aneurysms, infarctions, and mass lesions. Aspergillosis does not have a specific radiologic appearance. Parenchymal aspergillosis has heterogenous signal intensity (hypointense on T1-weighted and hyperintense on T2-weighted images). Here, we present 3 patients who underwent solid-organ transplant and developed central nervous system aspergillosis. Different modalities of neurosurgical intervention were performed in combination with chemotherapy as part of their fungal therapy.

Investigation of Aspergillus flavus in animal virulence

Aspergillus flavus is a common fungal pathogen of plants, animals and humans. Recently, many genes of A. flavus have been reported involving in regulation of pathogenesis in crops, but whether these genes are involved in animal virulence is still unknown. Here, we used a previous easy-to-use infection model for A. flavus based on mouse model by intravenous inoculation of A. flavus conidia. The outcome of infections in mice model showed that A. flavus NRRL3357 and laboratory strain CA14 PTS were both in dose dependent manner and highly reproducible. The progress of disease could be monitored by mice survival and histology analysis. Fungal burden analysis indicated it was gradually decreased within 7 days after infection. Moreover, aspergillosis caused by A. flavus significantly up-regulated gene expression levels of immune response mediators, including INF-γ, TNF-α, Dectin-1 and TLR2. Furthermore, the defined deletion A. flavus strains that previously displayed virulence in crop infection were also determined in this mouse model, and the results showed comparable degrees of infection in mice. Our results suggested that intravenous inoculation of conidia could be a suitable model for testing different A. flavus mutants in animal virulence. We hope to use this model to determine distinct A. flavus strains virulence in animals and study novel therapeutic methods to help control fungus diseases in the future.

Recent advances on topical antimicrobials for skin and soft tissue infections and their safety concerns

Antimicrobial resistance of disease-related microorganisms is considered a worldwide prevalent and serious issue which increases the failure of treatment outcomes and leads to high mortality. Considering that the increased resistance to systemic antimicrobial therapy often needs of the use of more toxic agents, topical antimicrobial therapy emerges as an attractive route for the treatment of infectious diseases. The topical antimicrobial therapy is based on the absorption of high drug doses in a readily accessible skin surface, resulting in a reduction of microbial proliferation at infected skin sites. Topical antimicrobials retain the following features: (a) they are able to escape the enzymatic degradation and rapid clearance in the gastrointestinal tract or the first-pass metabolism during oral administration; (b) alleviate the physical discomfort related to intravenous injection; (c) reduce possible adverse effects and drug interactions of systemic administrations; (d) increase patient compliance and convenience; and (e) reduce the treatment costs. Novel antimicrobials for topical application have been widely exploited to control the emergence of drug-resistant microorganisms. This review provides a description of antimicrobial resistance, common microorganisms causing skin and soft tissue infections, topical delivery route of antimicrobials, safety concerns of topical antimicrobials, recent advances, challenges and future prospective in topical antimicrobial development.

The importance of risk factors for the prediction of patients with invasive pulmonary aspergillosis

OBJECTIVE

Invasive pulmonary aspergillosis (IPA) is a major challenge in the management of immunocompromised patients. Despite all the advances in diagnosis, it remains a problem. The purpose of our study was to investigate the risk factors associated with IPA seen in patients with hematological malignancies.

METHOD

A total of 152 febrile neutropenia (FEN) patients with hematological malignancies aged over 18 years and receiving high-dose chemotherapy or stem cell transplant between January 1, 2010, and December 31, 2012 were included in the study. Sixty-five (65) cases with IPA according to the European Organization for the Research and Treatment of Cancer and Infectious Diseases Mycoses Study Group criteria were enrolled as the case group, while 87 patients without IPA development during concomitant monitoring were enrolled as the control group. Incidence of IPA was 21.4% (3/14) in patients receiving bone marrow transplant (allogeneic 2, autologous 1) and those cases were also added into the case group. The two groups were compared in terms of demographic, clinical and laboratory findings and risk factors associated with IPA investigated retrospectively.

RESULTS

Presence of relapse of primary disease, neutropenia for more than 3 weeks, presence of bacterial infection, and non-administration of antifungal prophylaxis were identified as risk factors associated with IPA.

CONCLUSION

It may be possible to reduce the incidence of the disease by eliminating preventable risk factors. Predicting those risks would, per se, enable early diagnosis and treatment and, thus, the mortality rate of these patients would unquestionably decline.

Comparative transcriptomics of Aspergillus fumigatus strains upon exposure to human airway epithelial cells

Aspergillus fumigatus is an opportunistic, ubiquitous, saprophytic mould that can cause severe allergic responses in atopic individuals as well as life-threatening infections in immunocompromised patients. A critical step in the establishment of infection is the invasion of airway epithelial cells by the inhaled fungi. Understanding how A. fumigatus senses and responds to airway cells is important to understand the pathogenesis of invasive pulmonary aspergillosis. Here, we analysed the transcriptomes of two commonly used clinical isolates, Af293 and CEA10, during infection of the A549 type II pneumocyte cell line in vitro. We focused our RNA-seq analysis on the core set of genes that are present in the genomes of the two strains. Our results suggest that: (a) A. fumigatus does not mount a conserved transcriptional response to airway epithelial cells in our in vitro model and (b) strain background and time spent in the tissue culture media have a greater impact on the transcriptome than the presence of host cells. Our analyses reveal both common and strain-specific transcriptional programmes that allow for the generation of hypotheses about gene function as it pertains to pathogenesis and the significant phenotypic heterogeneity that is observed among A. fumigatus isolates.

[Clinical features of children with acute lymphoblastic leukemia complicated by pulmonary infection after chemotherapy]

OBJECTIVE

To examine the clinical features of children with acute lymphoblastic leukemia (ALL) complicated by pulmonary infection after chemotherapy.

METHODS

The clinical data of 108 ALL children (115 case-times) with post-chemotherapy pulmonary infection were retrospectively reviewed. The risk factors for pulmonary infection and the relationship between pathogens and chest CT findings were evaluated.

RESULTS

The highest incidence (77.4% ) of pulmonary infection occurred during remission induction, peaking at 31-60 days after chemotherapy. Patients with neutropenia had the highest incidence rate of pulmonary infection (67.0%). Bacteria (36%) and fungi (41%) were the two most common pathogens in the 41 patients who were etiologically suspected of or diagnosed with pulmonary infection. There was no significant difference in chest CT findings between patients with bacterial and fungal infections.

CONCLUSIONS

The children with ALL are most susceptible to pulmonary infection during remission induction, especially when they are neutropenic. Bacteria and fungi are the main pathogens of pulmonary infections in these patients. However, the changes in chest CT images are poor indicators of the nature of pulmonary infection.

Free chlorine and monochloramine inactivation kinetics of Aspergillus and Penicillium in drinking water

Fungi are near-ubiquitous in potable water distribution systems, but the disinfection kinetics of commonly identified fungi are poorly studied. In the present study, laboratory scale experiments were conducted to evaluate the inactivation kinetics of Aspergillus fumigatus, Aspergillus versicolor, and Penicillium purpurogenum by free chlorine and monochloramine. The observed inactivation data were then fit to a delayed Chick-Watson model. Based on the model parameter estimation, the Ct values (integrated product of disinfectant concentration C and contact time t over defined time intervals) for 99.9% inactivation of the tested fungal strains ranged from 48.99 mg min/L to 194.7 mg min/L for free chlorine and from 90.33 mg min/L to 531.3 mg min/L for monochloramine. Fungal isolates from a drinking water system (Aspergillus versicolor and Penicillium purpurogenum) were more disinfection resistant than Aspergillus fumigatus type and clinical isolates. The required 99.9% inactivation Ct values for the tested fungal strains are higher than E. coli, a commonly monitored indicator bacteria, and within a similar range for bacteria commonly identified within water distribution systems, such as Mycobacterium spp. and Legionella spp.

Invasive Aspergillosis Involving the Mediastinum in an Immunocompetent Patient: A Case Report

We report a rare case of invasive pulmonary aspergillosis invading the mediastinum and the left atrium. A 38-year-old female was hospitalized for cough, shortness of breath and fever. She had a past medical history of tuberculosis. Computed tomography (CT) scans identified an ill-defined enhancing mediastinal soft tissue density mass encasing the heart and major vessels. The cardiac echocardiography showed global hypokinesia, low ejection fraction and a large echogenic density in the left atrium. The pathology from the bronchoscopic biopsy observed abundant fungal hyphae which were stained with periodic Acid-Schiff and Gomori's methenamine silver. Despite the treatment with antifungal agents, the patient could not be saved. Invasive pulmonary aspergillosis, which involves the mediastinum and the heart, is very rare in immunocompetent patients.

Multicenter Evaluation of Risk Factors for Aspergillosis in Patients Treated with Lipid Amphotericin B Products: Outcomes, Drug Utilization Parameters, and Benchmarking

Purpose

To evaluate the use of lipid amphotericin B products in relation to risk factors for aspergillosis and candidemia at the time therapy was initiated.

Methods

A single-group, concurrent, observational, multicenter study in hospitalized patients receiving a lipid amphotericin B product (Abelcet or AmBisome) was undertaken. The severity of illness, duration of therapy, length of hospital stay, microbiology, all-cause mortality, physician specialty, and clinical characteristics of each patient was recorded. Risk factors for aspergillosis and candidemia and process markers that might identify patients as candidates for lipid amphotericin B therapy were collected.

Results

One hundred eighty-six patients were enrolled in six US medical centers. One hundred four patients had positive fungal cultures; the majority of positive cultures were for Candida albicans (n = 40) or yeast (n = 27). Sixteen patients had positive cultures for Aspergillus. All patients receiving a lipid amphotericin B product had an overall statistically significantly greater number of risk factors for Candida vs Aspergillus infection. The mean (± SD) number of risk factors for Aspergillus was 2.46 ± 1.97 (range 0–10) and for Candida was 7.77 ± 3.14 (range 1–16) (P < 0.05). Risk factor assessment by medical service showed a statistically significantly larger number of Aspergillus risk factors in the bone marrow transplant (BMT) service compared with all other services (P < 0.05).

Conclusions

There were fewer documented risk factors for aspergillosis than candidemia in patients receiving a lipid amphotericin B product. Establishing drug usage protocols that include culture analysis, risk factor identification, high-risk medical services, and incorporation of drug use evaluation measures can guide the practitioner in selecting the appropriate therapy for their patients.

Flucytosine and Amphotericin B Coadministration Induces Dose-Related Renal Injury

Invasive fungal infections remain an important clinical problem, and despite recent approaches, they bring high morbidity and mortality. Combination therapies are the most effective; however, adverse effects need to be considered. In this study, we aimed to evaluate the nephrotoxicity induced by combined therapy of flucytosine (FL) and amphotericin B (AMF) at 3 different doses administered to mice for 14 days: 300 μg/kg AMF+50 mg/kg FL; 600 μg/kg AMF+100 mg/kg FL; 900 μg/kg AMF+150 mg/kg FL. Antifungal coadministration triggered nuclear translocation of NF-κB and upregulated nuclear factor kappa-light-chain-enhancer of activated B cells subunit p65 (NF-κB p65) messenger RNA mRNA level in dose-dependent manner. The immunopositivity of tumor necrosis factor-α and interleukin-6 (IL-6), together with IL-6 gene expression, increased both in tubular and glomerular cells. Amphotericin B–flucytosine cotreatment increased significantly the number of terminal deoxy-nucleotidyl transferase (TdT)-mediated dUTP nick end-labeling positive nuclei. Apoptotic cells in renal tubuli were confirmed by electron microscopy. Histopathological analysis revealed collagen accumulation at the glomerular level. Collagen was also evidenced in the glomeruli at the dose of 900 μg/kg AMF+150mg/kg FL by Masson-Goldner trichrome staining and electron microscopy. Moreover, antifungal cotherapy induced upregulation of transforming growth factor beta 1 (TGF-β1) gene expression in a dose-dependent manner. Inflammation and epithelial tubular apoptosis are associated with TGF-β1 activation and initiation of the early stage of glomerular fibrosis at higher doses, leading to tubule–interstitial fibrosis.

Serial assessment of pulmonary lesion volume by computed tomography allows survival prediction in invasive pulmonary aspergillosis

BACKGROUND

Serial chest CT is the standard of care to establish treatment success in invasive pulmonary aspergillosis (IPA). Data are lacking how response should be defined.

METHODS

Digital CT images from a clinical trial on treatment of IPA were re-evaluated and compared with available biomarkers. Total volume of pneumonia was added up after manual measurement of each lesion, followed by statistical analysis.

RESULTS

One-hundred and ninety CT scans and 309 follow-up datasets from 40 patients were available for analysis. Thirty-one were neutropenic. Baseline galactomannan (OR 4.06, 95%CI: 1.08-15.31) and lesion volume (OR 3.14, 95%CI: 0.73-13.52) were predictive of death. Lesion volume at d7 and trend between d7 and d14 were strong predictors of death (OR 20.01, 95%CI: 1.42-282.00 and OR 15.97, 95%CI: 1.62-157.32) and treatment being rated as unsuccessful (OR 4.75, 95%CI: 0.94-24.05 and OR 40.69, 95%CI: 2.55-649.03), which was confirmed by a Cox proportional hazards model using time-dependent covariates.

CONCLUSION

Any increase in CT lesion volume between day 7 and day 14 was a sensitive marker of a lethal outcome (>50%), supporting a CT rescan each one and 2 weeks after initial detection of IPA. The predictive value exceeded all other biomarkers. Further CT follow-up after response at day 14 was of low additional value.

KEY POINTS

• CT evaluation offers good prediction of outcome for invasive pulmonary aspergillosis. • Predictive capability exceeds galactomannan, blood counts, and lesion count. • Any progression between day 7 and day 14 constitutes a high-risk scenario.

Bilateral renal aspergillosis in an immunocompetent host

Bilateral primary renal aspergillosis is rare in immunocompetent hosts. The clinical presentation of Aspergillus pyelonephritis is similar to that of bacterial pyelonephritis. Here, we present an immunocompetent patient with primary bilateral renal abscesses due to Aspergillus fumigatus.

Invasive Mediastinal Aspergillosis in Immunocompetent Male with Invasion of Left Atrium and Hilar Structures

Aspergillus is described as mould characterised by septate hyphae about 2-4μ in diameter, it is ubiquitous in nature and spreads by inhalation of spores. It causes opportunistic infections in almost six forms namely Allergic bronchopulmonary aspergillosis, Aspergillus sinusitis, Cutaneous aspergillosis, Aspergilloma, Chronic pulmonary aspergillosis, Invasive aspergillosis. Invasive aspergillosis of mediastinum in an immunocompetent patient has rarely been reported. We present a case of a young male who had presented with chest pain, cough and breathleness was later diagnosed as fulminant mediastinal aspergillosis. Incisional biopsy with histology report and endotracheal cultures helped in diagnosing mediastinal aspergillosis. Despite initiation of the right antifungal therapy and best supportive measures, patient died of septic shock and multiorgan dysfunction. This case report highlights the need for higher suspicion in such cases of mediastinal masses and early tissue biopsy which can help in reducing mortality.

Medicolegal Implications of Nosocomial Infections: A Case Report of Aspergillus Contamination during Cardiac Surgery

Nosocomial infections have become a major issue of public health and lead to an increasing number of suits for damages. We present a rare case of Aspergillus contamination during cardiac surgery, describe the medicolegal investigation, and present the new system for compensation of bodily injury after nosocomial infection in France, based on the law of March 4, 2002 on patient rights and quality in the health system. This case demonstrates the limits of compensation for nosocomial infections on the grounds of national solidarity. The expert report requested by the regional commission for conciliation and compensation is of fundamental importance in enabling the commission to decide between fault and inherent risk of treatment.

Clinical manifestations and outcomes of pulmonary aspergillosis: experience from Pakistan

Introduction

Pulmonary aspergillosis has variable course of illness, severity and outcomes depending on underlying conditions. There is limited data available on the clinical manifestations and outcome of pulmonary aspergillosis from Pakistan.

Methods

To determine the clinical manifestations and outcome of pulmonary aspergillosis in a tertiary care hospital a retrospective study was conducted from 2004 to 2014 in patients admitted with pulmonary aspergillosis at the Aga Khan University Hospital Karachi, Pakistan.

Results

Of the 280 cases with provisional diagnosis of aspergillosis 69 met the inclusion criteria. The mean age was 45±15.7 years, 48 (69.6%) were men and 21 (30.4%) had diabetes mellitus (DM). The average length of hospital stay (LOS) was 10.61±9.08 days. Aspergillus fumigatus was the most common (42.0%), followed by Aspergillus flavus (28.9%). More than one-third of patients previously had tuberculosis (TB) (39.13%). The commonest pulmonary manifestation was chronic pulmonary aspergillosis (CPA) 47 (68.1%) followed by invasive pulmonary aspergillosis (IPA) 12 (17.4%) and subacute invasive aspergillosis (SAIA) 8 (11.6%). Surgical excision was performed in 28 patients (40.57%). Intensive care unit admission was required for 18 patients (26.08%). Case fatality rate was 14/69 (20.3%). DM, mean LOS and hypoxic respiratory failure were identified as independent risk factors of mortality on multivariate analysis.

Conclusion

A. fumigatus was the most frequent species found especially in patients with prior TB. CPA was the commonest pulmonary manifestation seen as post TB sequel. Diabetes, hypoxic respiratory failure and increased LOS were independent predictors of poor outcomes. Overall patients had good outcome with CPA compared with SAIA and IPA.

Invasive aspergillosis in acute myeloid leukemia: Are we making progress in reducing mortality?

The incidence of invasive fungal disease (IFD) has varied during the last decades. However, over the years, we have observed a progressive reduction of mortality, mainly due to wider use of prophylactic antifungal therapy (i.e., new azoles, such as posaconazole), the development of new and more effective antifungal drugs (lipid compounds of amphotericin B, candins, and azoles of the previous generation) and improvement of diagnostic tools. Based on a number of international studies across three decades, the attributable mortality rate for IFD and invasive aspergillosis (IA) among patients with acute myeloid leukemia (AML) has progressively declined. In the first report, in 2001, the attributable mortality rate for aspergillosis observed in AML patients by the GIMEMA (Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto) group was near 60%. A subsequent multicenter Italian study by SEIFEM (Sorveglianza Epidemiologica Infezioni Fungine nelle Emopatie Maligne) reported an attributable mortality of 38% among 3,012 patients recruited from 1999 through 2003. Further reduction to 27% was reported for patients diagnosed between 2004 and 2007 in another SEIFEM study. Over the last few years, a different trend in mortality for IA has been observed in the various phases of therapy in patients with acute leukemia: while in the induction phase of treatment, characterized by a higher incidence of IA, we observed a reduction of mortality over the years, among relapsed/refractory patients, the mortality remains dramatically high.

Efficacy and safety of itraconazole use in infants

BACKGROUND

Itraconazole has been used to treat fungal infections, in particular invasive fungal infections in infants or neonates in many countries.

DATA SOURCES

Literature search was conducted through Ovid EMBASE, PubMed, ISI Web of Science, CNKI and Google scholarship using the following key words: "pediatric" or "infant" or "neonate" and "fungal infection" in combination with "itraconazole". Based on the literature and our clinical experience, we outline the administration of itraconazole in infants in order to develop evidence-based pharmacotherapy.

RESULTS

Of 45 articles on the use of itraconazole in infancy, 13 are related to superficial fungal infections including tinea capitis, sporotrichosis, mucosal fungal infections and opportunistic infections. The other 32 articles are related to systemic fungal infections including candidiasis, aspergillosis, histoplasmosis, zygomycosis, trichosporonosis and opportunistic infections as caused by Myceliophthora thermophila.

CONCLUSION

Itraconazole is safe and effective at a dose of 5 mg/kg per day in a short duration of therapy for superficial fungal infections and 10 mg/kg per day for systemic fungal infections in infants. With a good compliance, it is cost-effective in treating infantile fungal infections. The profiles of adverse events induced by itraconazole in infants are similar to those in adults and children.

Invasive Aspergillosis: Current Strategies for Diagnosis and Management

Aspergillosis remains a significant cause of morbidity and mortality in the immunocompromised population. The spectrum of disease is broad, ranging from severe and rapidly fatal infection to noninvasive disease. The diversity of patients and risk factors complicates diagnostic and therapeutic decision-making. Invasive procedures are often precluded by host status; noninvasive diagnostic tests vary in their sensitivity and specificity. Advancements in understanding the pathophysiology of invasive aspergillosis and host genetics in differential risk have also occurred. Future work may assist in therapeutic decision-making and patient prognosis. Voriconazole remains the preferred agent for treatment. Additional alternatives have emerged.

Modified release itraconazole amorphous solid dispersion to treat Aspergillus fumigatus: importance of the animal model selection

Previously, modified release itraconazole in the form of a melt-extruded amorphous solid dispersion based on a pH dependent enteric polymer combined with hydrophilic additives (HME-ITZ), exhibited improved in vitro dissolution properties. These properties agreed with pharmacokinetic results in rats showing high and sustained itraconazole (ITZ) systemic levels. The objective of the present study was to better understand the best choice of rodent model for evaluating the pharmacokinetic and efficacy of this orally administered modified release ITZ dosage form against invasive Aspergillus fumigatus. A mouse model and a guinea pig model were investigated and compared to results previously published. In the mouse model, despite similar levels as previously reported values, plasma and lung levels were variable and fungal burden was not statistically different for placebo controls, HME-ITZ and Sporanox^® (ITZ oral solution). This study demonstrated that the mouse model is a poor choice for studying modified release ITZ dosage forms based on pH dependent enteric polymers due to low fluid volume available for dissolution and low intestinal pH. To the contrary, guinea pig was a suitable model to evaluate modified release ITZ dosage forms. Indeed, a significant decrease in lung fungal burden as a result of high and sustained ITZ tissue levels was measured. Sufficiently high intestinal pH and fluids available for dissolution likely facilitated the dissolution process. Despite high ITZ tissue level, the primary therapeutic agent voriconazole exhibited an even more pronounced decrease in fungal burden due to its reported higher clinical efficacy specifically against Aspergillus fumigatus.

Population Pharmacokinetics of Isavuconazole from Phase 1 and Phase 3 (SECURE) Trials in Adults and Target Attainment in Patients with Invasive Infections Due to Aspergillus and Other Filamentous Fungi

Isavuconazole, the active moiety of the water-soluble prodrug isavuconazonium sulfate, is a triazole antifungal agent used for the treatment of invasive fungal infections. The objective of this analysis was to develop a population pharmacokinetic (PPK) model to identify covariates that affect isavuconazole pharmacokinetics and to determine the probability of target attainment (PTA) for invasive aspergillosis patients. Data from nine phase 1 studies and one phase 3 clinical trial (SECURE) were pooled to develop the PPK model (NONMEM, version 7.2). Stepwise covariate modeling was performed in Perl-speaks-NONMEM, version 3.7.6. The area under the curve (AUC) at steady state was calculated for 5,000 patients by using Monte Carlo simulations. The PTA using the estimated pharmacodynamic (PD) target value (total AUC/MIC ratio) estimated from in vivo PD studies of invasive aspergillosis over a range of MIC values was calculated using simulated patient AUC values. A two-compartment model with a Weibull absorption function and a first-order elimination process adequately described plasma isavuconazole concentrations. The mean estimate for isavuconazole clearance was 2.360 liters/h (percent coefficient of variation [%CV], 34%), and the mean AUC from 0 to 24 h (AUC0-24) was ∼100 mg·h/liter. Clearance was approximately 36% lower in Asians than in Caucasians. The PTA calculated over a range of MIC values by use of the nonneutropenic murine efficacy index corresponding to 90% survival indicated that adequate isavuconazole exposures were achieved in >90% of simulated patients to treat infections with MICs up to and including 1 mg/liter according to European Committee on Antimicrobial Susceptibility Testing methodology and in >90% of simulated patients for infections with MICs up to and including 0.5 mg/liter according to Clinical and Laboratory Standards Institute methodology. The highest MIC result for PTA was the same for Caucasian and Asian patients.

Estimated burden of fungal infections in Germany

In the late 1980's, the incidence of invasive fungal diseases (IFDs) in Germany was estimated with 36.000 IFDs per year. The current number of fungal infections (FI) occurring each year in Germany is still not known. In the actual analysis, data on incidence of fungal infections in various patients groups at risk for FI were calculated and mostly estimated from various (mostly national) resources. According to the very heterogenous data resources robust data or statistics could not be obtained but preliminary estimations could be made and compared with data from other areas in the world using a deterministic model that has consistently been applied in many countries by the LIFE program ( www.LIFE-worldwide.org). In 2012, of the 80.52 million population (adults 64.47 million; 41.14 million female, 39.38 million male), 20% are children (0-14 years) and 16% of population are ≥65 years old. Using local data and literature estimates of the incidence or prevalence of fungal infections, about 9.6 million (12%) people in Germany suffer from a fungal infection each year. These figures are dominated (95%) by fungal skin disease and recurrent vulvo-vaginal candidosis. In general, considerable uncertainty surrounds the total numbers because IFDs do not belong to the list of reportable infectious diseases in Germany and most patients were not hospitalised because of the IFD but a distinct underlying disease.

Recent developments in the management of invasive fungal infections in patients with oncohematological diseases

Patients with hematological cancer have a high risk of invasive fungal diseases (IFDs). These infections are mostly life threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Most commonly, Aspergillus and Candida species are involved. However, other non-Aspergillus molds are increasingly be identified in cases of documented IFDs. Important risk factors are long lasting granulocytopenia with neutrophil counts below 500/μl for more than 10 days or graft-versus-host disease resulting from allogeneic stem-cell transplantation. For definite diagnosis of IFD, various diagnostic tools have to be applied, including conventional mycological culture and nonconventional microbiological tests such as antibody/antigen and molecular tests, as well as histopathology and radiology. In the last few years, various laboratory methods, like the Aspergillus GM immunoassay (Aspergillus GM EIA), 1,3-ß-D-glucan (BG) assay or polymerase chain reaction (PCR) techniques have been developed for better diagnosis. Since no single indirect test, including radiological methods, provides the definite diagnosis of an invasive fungal infection, the combination of different diagnostic procedures, which include microbiological cultures, histological, serological and molecular methods like PCR together with the pattern of clinical presentation, may currently be the best strategy for the prompt diagnosis, initiation and monitoring of IFDs. Early start of antifungal therapy is mandatory, but clinical diagnostics often do not provide clear evidence of IFD. Integrated care pathways have been proposed for management and therapy of IFDs with either the diagnostic driven strategy using the preemptive antifungal therapy as opposed to the clinical or empirical driven strategy using the 'traditional' empirical antifungal therapy. Antifungal agents preferentially used for systemic therapy of invasive fungal infections are amphotericin B preparations, fluconazole, voriconazole, posaconazole, caspofungin, anidulafungin, micafungin, and most recently isavuconazole. Clinical decision making must consider licensing status, local experience and availability, pharmacological and economic aspects.

Central nervous system aspergillosis in an immunocompetent patient: Cure in a hospice setting with very high-dose itraconazole

Aspergillosis of the central nervous system (CNS) is a rare condition with exceedingly high mortality. This study describes the case of an immunocompetent 42-year-old man with a history of intravenous drug use and hepatitis C who developed multiple Aspergillus lesions in the cerebellum. Despite neurosurgery and antifungal therapy with amphotericin B, he had a protracted hospital course with multiple complications, eventually developing cognitive and motor impairment due to progressive cerebellar lesions. After transfer to hospice and palliative care service, oral itraconazole was escalated to 1600 mg/day with the hope of palliating headache, nausea, and cognitive impairment. Remarkably, the patient stabilized and improved over time. After 14 months, this unprecedented high-dose regimen was discontinued, and the patient was discharged home with only mild cerebellar motor impairment.

Factors affecting patient outcome in primary cutaneous aspergillosis

Primary cutaneous aspergillosis (PCA) is an uncommon infection of the skin. There is a paucity of organized literature regarding this entity in regard to patient characteristics, associated Aspergillus species, and treatment modalities on outcome (disease recurrence, disease dissemination, and mortality).We reviewed all published reports of PCA from 1967 to 2015. Cases were deemed eligible if they included the following: patient baseline characteristics (age, sex, underlying condition), evidence of proven or probable PCA, primary treatment strategy, and outcome.We identified 130 eligible cases reported from 1967 to 2015. The patients were predominantly male (63.8%) with a mean age of 30.4 ± 22.1 years. Rates of PCA recurrence, dissemination, and mortality were 10.8%, 18.5%, and 31.5%, respectively. In half of the cases, there was an association with a foreign body. Seven different Aspergillus species were reported to cause PCA. Systemic antifungal therapy without surgery was the most common form of therapy (60% of cases). Disease dissemination was more common in patients with underlying systemic conditions and occurred on average 41.4 days after PCA diagnosis (range of 3-120 days). In a multivariate linear regression model of mortality including only patients with immunosuppressive conditions, dissemination and human immunodeficiency virus/acquired immune deficiency syndrome were statistically significantly associated with increased mortality.Nearly one-third of patients with PCA die with the disease. Dissemination and host status are critical in patient outcome.

Genome Sequencing and Evolutionary Analysis of Marine Gut Fungus Aspergillus sp. Z5 from Ligia oceanica

Aspergillus sp. Z5, isolated from the gut of marine isopods, produces prolific secondary metabolites with new structure and bioactivity. Here, we report the draft sequence of the approximately 33.8-Mbp genome of this strain. To the best of our knowledge, this is the first genome sequence of Aspergillus strain isolated from marine isopod Ligia oceanica. The phylogenetic analysis supported that this strain was closely related to A. versicolor, and genomic analysis revealed that Aspergillus sp. Z5 shared a high degree of colinearity with the genome of A. sydowii. Our results may facilitate studies on discovering the biosynthetic pathways of secondary metabolites and elucidating their evolution in this species.

A Critical Reappraisal of Prolonged Neutropenia as a Risk Factor for Invasive Pulmonary Aspergillosis

Prolonged neutropenia is generally thought to be the major factor for invasive pulmonary aspergillosis (IPA). In the present study, we characterize the frequency, severity, and duration of neutropenia that immediately precedes IPA. Prolonged neutropenia was identified in only one third of all IPA cases and occurred exclusively in hematologic patients.