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Chaniotakis C, Koutserimpas C, Tsantes AG, Papadopoulos DV, Tsiridis CA, Karantanas A, Alpantaki K, Hadjipavlou A. Post-Discectomy Infection: A Critical Review and Suggestion of a Management Algorithm. J Clin Med 2024; 13:1478. [PMID: 38592315 PMCID: PMC10935210 DOI: 10.3390/jcm13051478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/18/2024] [Accepted: 03/01/2024] [Indexed: 04/10/2024] Open
Abstract
Postoperative discitis (POD) accounts for 20% to 30% of all cases of pyogenic spondylodiscitis, while POD may be mis-or-under-diagnosed, due to the vague related symptomatology and the non-specific imaging findings. Most studies report infection rate of less than 1%, which increases with the addition of non-instrumented fusion to 2.4% to 6.2%. It remains controversial whether POD is caused by an aseptic or infectious process. Positive cultures are presented only in 42-73% of patients with Staphylococcus species being the most common invading organisms, while Staphylococcus aureus is isolated in almost 50% of cases. The onset of POD symptoms usually occurs at 2-4 weeks after an apparently uneventful operation. Back pain and muscle spasms are usually refractory to bed rest and analgesics. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging diagnostic technique. Antimicrobial therapy depends on the results of tissue cultures, and along with bracing represents the mainstay of management. Surgical intervention is necessary in patients failing conservative treatment. For the majority of cases, extensive surgical debridement, antibiotic therapy, and orthosis immobilization are effective in eliminating the infection. According to this, we recommend an Algorithmic approach for the management of POD. Postoperative infections after spinal surgery pose a certain clinical challenge, and in most cases can be treated conservatively. Nevertheless, disability may be persistent, and surgery could be necessary. The purpose of this concise review is to describe the manifestation of post-discectomy infection, its pathogenesis and particularly a rational approach for its management.
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Affiliation(s)
- Constantinos Chaniotakis
- Department of Orthopaedics and Trauma Surgery, “Venizeleion” General Hospital of Heraklion, 71409 Crete, Greece; (C.C.); (K.A.)
| | - Christos Koutserimpas
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, 11525 Athens, Greece
- Department of Anatomy, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Andreas G. Tsantes
- Laboratory of Haematology and Blood Bank Unit, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
- Microbiology Department, Saint Savvas Oncology Hospital, 11522 Athens, Greece
| | - Dimitrios V. Papadopoulos
- Second Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 14233 Athens, Greece;
| | | | | | - Kalliopi Alpantaki
- Department of Orthopaedics and Trauma Surgery, “Venizeleion” General Hospital of Heraklion, 71409 Crete, Greece; (C.C.); (K.A.)
| | - Alexander Hadjipavlou
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77550, USA;
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Strong N, Meeks G, Sheth SA, McCullough L, Villalba JA, Tan C, Barreto A, Wanger A, McDonald M, Kan P, Shaltoni H, Campo Maldonado J, Parada V, Hassan AE, Reagan-Steiner S, Chiller T, Gold JAW, Smith DJ, Ostrosky-Zeichner L. Neurovascular Complications of Iatrogenic Fusarium solani Meningitis. N Engl J Med 2024; 390:522-529. [PMID: 38324485 DOI: 10.1056/nejmoa2308192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
A multinational outbreak of nosocomial fusarium meningitis occurred among immunocompetent patients who had undergone surgery with epidural anesthesia in Mexico. The pathogen involved had a high predilection for the brain stem and vertebrobasilar arterial system and was associated with high mortality from vessel injury. Effective treatment options remain limited; in vitro susceptibility testing of the organism suggested that it is resistant to all currently approved antifungal medications in the United States. To highlight the severe complications associated with fusarium infection acquired in this manner, we report data, clinical courses, and outcomes from 13 patients in the outbreak who presented with symptoms after a median delay of 39 days.
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Affiliation(s)
- Nora Strong
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Grant Meeks
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Sunil A Sheth
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Louise McCullough
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Julian A Villalba
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Chunfeng Tan
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Andrew Barreto
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Audrey Wanger
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Michelle McDonald
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Peter Kan
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Hashem Shaltoni
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Jose Campo Maldonado
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Victoria Parada
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Ameer E Hassan
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Sarah Reagan-Steiner
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Tom Chiller
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Jeremy A W Gold
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Dallas J Smith
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
| | - Luis Ostrosky-Zeichner
- From McGovern Medical School, University of Texas Health Science Center at Houston, Houston (N.S., G.M., S.A.S., L.M., C.T., A.B., A.W., M.M., L.O.-Z.), the University of Texas Medical Branch, Galveston (P.K., H.S.), and the University of Texas Rio Grande Valley-Harlingen, Harlingen (J.C.M., V.P., A.E.H.) - all in Texas; and the Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases (J.A.V., S.R.-S.), and the Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases (T.C., J.A.W.G., D.J.S.), Centers for Disease Control and Prevention, Atlanta
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Drozd M, Ritter JM, Samuelson JP, Parker M, Wang L, Sander SJ, Yoshicedo J, Wright L, Odani J, Shrader T, Lee E, Lockhart SR, Ghai RR, Terio KA. Mortality associated with SARS-CoV-2 in nondomestic felids. Vet Pathol 2024:3009858231225500. [PMID: 38323378 DOI: 10.1177/03009858231225500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Between September and November 2021, 5 snow leopards (Panthera uncia) and 1 lion (Panthera leo) were naturally infected with severe acute respiratory coronavirus 2 (SARS-CoV-2) and developed progressive respiratory disease that resulted in death. Severe acute respiratory syndrome coronavirus 2 sequencing identified the delta variant in all cases sequenced, which was the predominant human variant at that time. The time between initial clinical signs and death ranged from 3 to 45 days. Gross lesions in all 6 cats included nasal turbinate hyperemia with purulent discharge and marked pulmonary edema. Ulcerative tracheitis and bronchitis were noted in 4 cases. Histologically, there was necrotizing and ulcerative rhinotracheitis and bronchitis with fibrinocellular exudates and fibrinosuppurative to pyogranulomatous bronchopneumonia. The 4 cats that survived longer than 8 days had fungal abscesses. Concurrent bacteria were noted in 4 cases, including those with more acute disease courses. Severe acute respiratory syndrome coronavirus 2 was detected by in situ hybridization using probes against SARS-CoV-2 spike and nucleocapsid genes and by immunohistochemistry. Viral nucleic acid and protein were variably localized to mucosal and glandular epithelial cells, pneumocytes, macrophages, and fibrinocellular debris. Based on established criteria, SARS-CoV-2 was considered a contributing cause of death in all 6 cats. While mild clinical infections are more common, these findings suggest that some SARS-CoV-2 variants may cause more severe disease and that snow leopards may be more severely affected than other felids.
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Affiliation(s)
- Mary Drozd
- University of Nebraska-Lincoln, Lincoln, NE
| | - Jana M Ritter
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Leyi Wang
- University of Illinois Urbana-Champaign, Urbana, IL
| | | | | | - Louden Wright
- Great Plain Zoo, Sioux Falls, SD
- Nashville Zoo at Grassmere, Nashville, TN
| | - Jenee Odani
- University of Hawai'i at Mānoa, Honolulu, HI
| | | | - Elizabeth Lee
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Ria R Ghai
- Centers for Disease Control and Prevention, Atlanta, GA
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4
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Drozd M, Ritter JM, Samuelson JP, Parker M, Wang L, Sander SJ, Yoshicedo J, Wright L, Odani J, Shrader T, Lee E, Lockhart SR, Ghai RR, Terio KA. Mortality associated with SARS-CoV-2 in nondomestic felids. Vet Pathol 2024. [DOI: https:/doi.org/10.1177/03009858231225500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Between September and November 2021, 5 snow leopards ( Panthera uncia) and 1 lion ( Panthera leo) were naturally infected with severe acute respiratory coronavirus 2 (SARS-CoV-2) and developed progressive respiratory disease that resulted in death. Severe acute respiratory syndrome coronavirus 2 sequencing identified the delta variant in all cases sequenced, which was the predominant human variant at that time. The time between initial clinical signs and death ranged from 3 to 45 days. Gross lesions in all 6 cats included nasal turbinate hyperemia with purulent discharge and marked pulmonary edema. Ulcerative tracheitis and bronchitis were noted in 4 cases. Histologically, there was necrotizing and ulcerative rhinotracheitis and bronchitis with fibrinocellular exudates and fibrinosuppurative to pyogranulomatous bronchopneumonia. The 4 cats that survived longer than 8 days had fungal abscesses. Concurrent bacteria were noted in 4 cases, including those with more acute disease courses. Severe acute respiratory syndrome coronavirus 2 was detected by in situ hybridization using probes against SARS-CoV-2 spike and nucleocapsid genes and by immunohistochemistry. Viral nucleic acid and protein were variably localized to mucosal and glandular epithelial cells, pneumocytes, macrophages, and fibrinocellular debris. Based on established criteria, SARS-CoV-2 was considered a contributing cause of death in all 6 cats. While mild clinical infections are more common, these findings suggest that some SARS-CoV-2 variants may cause more severe disease and that snow leopards may be more severely affected than other felids.
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Affiliation(s)
- Mary Drozd
- University of Nebraska–Lincoln, Lincoln, NE
| | | | | | | | - Leyi Wang
- University of Illinois Urbana-Champaign, Urbana, IL
| | | | | | - Louden Wright
- Great Plain Zoo, Sioux Falls, SD
- Nashville Zoo at Grassmere, Nashville, TN
| | - Jenee Odani
- University of Hawai‘i at Mānoa, Honolulu, HI
| | | | - Elizabeth Lee
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Ria R. Ghai
- Centers for Disease Control and Prevention, Atlanta, GA
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5
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Ilha MRS, Weaver D, Graham EA. Granulomatous dermatitis caused by Exserohilum mcginnisii infection in a cow. J Vet Diagn Invest 2024; 36:137-141. [PMID: 37933786 PMCID: PMC10734578 DOI: 10.1177/10406387231210861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
A 5-y-old, Piedmontese cow had a 4-mo history of ongoing development of skin masses. This was the only cow affected in a herd of 20 cows. Up to 12, hairless, red-to-black, raised nodules-to-plaques were distributed along the dorsum and tail head. Biopsies were taken for histopathology and ancillary testing. An ulcerated skin section contained dermal infiltrates of eosinophils, plasma cells, neutrophils, macrophages, lymphocytes, and multinucleate giant cells, and pyogranulomas. Fungal hyphae were seen within the dermis, multinucleate giant cells, and pyogranulomas. In pyogranulomas, fungi were surrounded by a Splendore-Hoeppli reaction. Dematiaceous (pigmented) hyphae were rarely observed with H&E-stained and unstained (cleared and mounted) sections, but stained well with a Fontana-Masson stain. Exserohilum mcginnisii was identified by fungal culture, followed by PCR assay and sequencing. Exserohilum is a dematiaceous fungus that causes disease in humans and rarely in animals. The use of unstained sections and Fontana-Masson stain are important to demonstrate pigment because dematiaceous fungi have little melanin and appear as hyaline hyphae histologically. PCR assay and sequencing aid in the differentiation and classification of fungal species. To our knowledge, E. mcginnisii dermal granulomas have not been reported previously in cattle.
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Affiliation(s)
- Marcia R. S. Ilha
- Veterinary Diagnostic and Investigational Laboratory, University of Georgia, Tifton, GA, USA
| | | | - Erin A. Graham
- Veterinary Diagnostic and Investigational Laboratory, University of Georgia, Tifton, GA, USA
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Douglas AP, Stewart AG, Halliday CL, Chen SCA. Outbreaks of Fungal Infections in Hospitals: Epidemiology, Detection, and Management. J Fungi (Basel) 2023; 9:1059. [PMID: 37998865 PMCID: PMC10672668 DOI: 10.3390/jof9111059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
Nosocomial clusters of fungal infections, whilst uncommon, cannot be predicted and are associated with significant morbidity and mortality. Here, we review reports of nosocomial outbreaks of invasive fungal disease to glean insight into their epidemiology, risks for infection, methods employed in outbreak detection including genomic testing to confirm the outbreak, and approaches to clinical and infection control management. Both yeasts and filamentous fungi cause outbreaks, with each having general and specific risks. The early detection and confirmation of the outbreak are essential for diagnosis, treatment of affected patients, and termination of the outbreak. Environmental sampling, including the air in mould outbreaks, for the pathogen may be indicated. The genetic analysis of epidemiologically linked isolates is strongly recommended through a sufficiently discriminatory approach such as whole genome sequencing or a method that is acceptably discriminatory for that pathogen. An analysis of both linked isolates and epidemiologically unrelated strains is required to enable genetic similarity comparisons. The management of the outbreak encompasses input from a multi-disciplinary team with epidemiological investigation and infection control measures, including screening for additional cases, patient cohorting, and strict hygiene and cleaning procedures. Automated methods for fungal infection surveillance would greatly aid earlier outbreak detection and should be a focus of research.
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Affiliation(s)
- Abby P. Douglas
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC 3000, Australia
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC 3084, Australia
| | - Adam G. Stewart
- Centre for Clinical Research, Faculty of Medicine, Royal Brisbane and Women’s Hospital Campus, The University of Queensland, Herston, QLD 4006, Australia;
| | - Catriona L. Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, NSW 2145, Australia; (C.L.H.); (S.C.-A.C.)
| | - Sharon C.-A. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, NSW 2145, Australia; (C.L.H.); (S.C.-A.C.)
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
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7
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Lockhart SR, Bialek R, Kibbler CC, Cuenca-Estrella M, Jensen HE, Kontoyiannis DP. Molecular Techniques for Genus and Species Determination of Fungi From Fresh and Paraffin-Embedded Formalin-Fixed Tissue in the Revised EORTC/MSGERC Definitions of Invasive Fungal Infection. Clin Infect Dis 2021; 72:S109-S113. [PMID: 33709128 DOI: 10.1093/cid/ciaa1836] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The EORTC/MSGERC have revised the definitions for proven, probable, and possible fungal diseases. The tissue diagnosis subcommittee was tasked with determining how and when species can be determined from tissue in the absence of culture. The subcommittee reached a consensus decision that polymerase chain reaction (PCR) from tissue, but not immunohistochemistry or in situ hybridization, can be used for genus or species determination under the new EORTC/MSGERC guidelines, but only when fungal elements are identified by histology. Fungal elements seen in tissue samples by histopathology and identified by PCR followed by sequencing should fulfill the definition of a proven fungal infection, identified to genus/species, even in the absence of culture. This summary discusses the issues that were deliberated by the subcommittee to reach the consensus decision and outlines the criteria a laboratory should follow in order to produce data that meet the EORTC/MSGERC definitions.
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Affiliation(s)
- Shawn R Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ralf Bialek
- LADR GmbH MVZ Dr. Kramer und Kollegen, Geesthacht, Germany
| | | | - Manuel Cuenca-Estrella
- Laboratorio de referencia e investigación en Micología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Spain
| | - Henrik E Jensen
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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8
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Lysen C, Silva-Flannery L, Zaki SR, Gary JM, Lockhart SR. Performance evaluation of fungal DNA PCR amplification from formalin-fixed paraffin-embedded tissue for diagnosis: Experience of a tertiary reference laboratory. Mycoses 2021; 64:603-611. [PMID: 33527526 DOI: 10.1111/myc.13249] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diagnosis of invasive fungal infections from formalin-fixed paraffin-embedded (FFPE) tissues by PCR amplification is a developing technology. One of the difficulties of establishing a validated protocol for this testing is that the gold standard, culture, is much less sensitive than the test being validated. OBJECTIVES To validate FFPE PCR as a refence laboratory identification methodology in the absence of abundant gold standard specimens. METHODS In this validation, PCR from FFPE tissue was compared to other diagnostic methods for genus/species identification. Four different groups of correlative data from FFPE tissues were used to validate this procedure. Thirteen specimens had culture or serology results and FFPE PCR results, 49 specimens had both immunohistochemistry (IHC) identification and FFPE PCR results, 118 specimens had histological evidence of fungal elements, 64 of which also had FFPE PCR results, and 36 fungal mock tissues or fungal negative tissues were used. RESULTS The sensitivity determined from the tissues with positive fungal histopathology was 54%. The specificity of the cases for which there were both culture and FFPE PCR results was 100%. For the correlation with IHC, the specificity was 98%. For the mock tissues and fungal negative tissues, the calculated analytical sensitivity was 94%, specificity was 95%, and accuracy was 94%. CONCLUSIONS By uniquely combining various data sources, this study provides a comprehensive framework for how validation can be achieved in the absence of a gold standard and outlines the excellent performance of PCR from FFPE tissue, despite relatively the low sensitivity when compared to histopathology.
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Affiliation(s)
- Colleen Lysen
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Luciana Silva-Flannery
- Infectious Disease Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sherif R Zaki
- Infectious Disease Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joy M Gary
- Infectious Disease Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Shawn R Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
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9
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Malani AN, Kauffman CA, Latham R, Peglow S, Ledtke CS, Kerkering TM, Kaufman DH, Triplett PF, Wright PW, Bloch KC, McCotter O, Toda M, Jackson BR, Pappas PG, Chiller TM. Long-term Outcomes of Patients With Fungal Infections Associated With Contaminated Methylprednisolone Injections. Open Forum Infect Dis 2020; 7:ofaa164. [PMID: 32528999 PMCID: PMC7275232 DOI: 10.1093/ofid/ofaa164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 11/15/2022] Open
Abstract
Background The largest health care–associated infection outbreak in the United States occurred during 2012–2013. Following injection of contaminated methylprednisolone, 753 patients developed infection with a dematiaceous mold, Exserohilum rostratum. The long-term outcomes of these infections have not been described. Methods This retrospective cohort study of 440 of a total of 753 patients with proven or probable Exserohilum infection evaluated clinical and radiographic findings, antifungal therapy and associated adverse effects, and outcomes at 6 weeks, 3, 6, 9, and 12 months after diagnosis. Patients were grouped into 4 disease categories: meningitis with/without stroke, spinal or paraspinal infections, meningitis/stroke plus spinal/paraspinal infections, and osteoarticular infections. Results Among the 440 patients, 223 (51%) had spinal/paraspinal infection, 82 (19%) meningitis/stroke, 123 (28%) both, and 12 (3%) osteoarticular infection. Of 82 patients with meningitis/stroke, 18 (22%) died; among those surviving, 87% were cured at 12 months. Only 7 (3%) of 223 patients with spinal/paraspinal infection died, but at 12 months, 68% had persistent or worsening pain and only 47% were cured. For the 123 patients with both meningitis/stroke and spinal/paraspinal infection, 10 (8%) died, pain persisted in 72%, and 52% were cured at 12 months. Only 37% of those with osteoarticular infection were cured at 12 months. Adverse events from antifungal therapy were noted at 6 weeks in 71% of patients on voriconazole and 81% on amphotericin B. Conclusions Fungal infections related to contaminated methylprednisolone injections culminated in death in 8% of patients. Persistent pain and disability were seen at 12 months in most patients with spinal/paraspinal infections.
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Affiliation(s)
| | - Carol A Kauffman
- VA Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert Latham
- St. Thomas Medical Center and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | | | | | | | - Patty W Wright
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karen C Bloch
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Orion McCotter
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mitsuru Toda
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Peter G Pappas
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tom M Chiller
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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10
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Mazlan MZ, Chong SE, Salmuna Ayub ZN, Mohamad NAN. Lumbar tinea versicolor and spinal anaesthesia. IDCases 2019; 16:e00520. [PMID: 31024798 PMCID: PMC6477118 DOI: 10.1016/j.idcr.2019.e00520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/09/2018] [Accepted: 03/06/2019] [Indexed: 11/28/2022] Open
Abstract
The risk of meningitis is very low in lumbar tinea versicolor parturient. Meticulous skin preparation to reduce the likelihood of infection transmission into subarachnoid space. Chlorhexidine 0.5% with 70% alcohol is antiseptic skin preparation.
Infection to the meningeal layer causing meningitis is one of the most feared complications of spinal anaesthesia. Anaesthetists will avoid spinal anaesthesia for those who are having skin infection at the puncture site. However in obstetric population, anaesthetist will try their best to avoid general anaesthesia due to its unwanted effects and complications. Strict and appropriate antiseptic measures such as chlorhexidine 0.5% with 70% alcohol has been suggested to reduce risk of transmission of microorganisms into subarachnoid space. We reported a parturient who had generalized tinea versicolor at the lumbar area, safely anaesthetized under spinal anaesthesia through meticulous antiseptic skin preparation who required delivery by caesarean section.
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Affiliation(s)
- Mohd Zulfakar Mazlan
- Department of Anaesthesiology, School of Medical Sciences, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Soon Eu Chong
- Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam 13200 Kepala Batas, Pulau Pinang, Malaysia
| | - Zeti Norfidiyati Salmuna Ayub
- Department of Microbiology and Parasitology, School of Medical Sciences, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Nik Abdullah Nik Mohamad
- Department of Anaesthesiology, School of Medical Sciences, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia
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11
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Liu Y, Gong W, Yu Y, Jiang L. Exserohilum Peritonitis in Peritoneal Dialysis in Northern China: A Case Report. Perit Dial Int 2019; 39:175-176. [PMID: 30858284 DOI: 10.3747/pdi.2018.00184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Fungal peritonitis is a catastrophic complication of peritoneal dialysis (PD) and often requires termination of PD. It is usually caused by Candida species. Here we report a rare case of Exserohilum peritonitis. The patient was successfully treated with catheter removal and anti-fungal therapy.
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Affiliation(s)
- Yan Liu
- Department of Infectious Disease, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Institution, Yantai, China.,Shandong Provicial Hospital of Shandong University, Jinan, China
| | - Wenjing Gong
- Department of Oncology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Institution, Yantai, China
| | - Yanming Yu
- Nephrology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Institution, Yantai, China
| | - Lihua Jiang
- Microbiology Laboratory, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Institution, Yantai, China
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12
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More SN, Hernandez O, Castleman WL. Mycotic Rhinitis and Sinusitis in Florida Horses. Vet Pathol 2018; 56:586-598. [PMID: 30558508 DOI: 10.1177/0300985818817046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Rhinitis and sinusitis caused by fungal pathogens were studied in biopsy samples submitted from 52 horses distributed throughout subtropical and tropical regions of Florida. Methods included routine histopathology as well as polymerase chain reaction (PCR) with panfungal/panoomycete primers and DNA sequencing on extracted DNA (DNA barcoding). Granulomatous, pyogranulomatous, and fibrinopurulent lesions in nasal and sinus mucosa were associated with signs of upper airway obstruction and noise as well as nasal discharge. Morphologic and histochemical assessment of cases identified 31 cases of zygomycosis/pythiosis plus 1 mixed infection case, 16 cases of phaeohyphomycosis with 2 additional mixed infection cases, and 3 cases caused by other fungi. Morphologic evidence of Aspergillus sp. infection as a superficial copathogen was found in 2 of the mixed fungal infection cases. PCR and DNA sequencing facilitated identification of fungal pathogens in 11 of 52 cases (21%). No evidence of oomycete infection was found. Histomorphologic features of previously unrecognized forms of equine rhinitis/sinusitis were described, including those caused by Flavodon flavus, Curvularia lunata, Exserohilum rostrata, Alternaria alternata, Alternaria sp., Cladophialophora bantiana, Fusarium solani, and Toxicocladosporium irritans. PCR and DNA sequencing using panfungal and oomycete primers with DNA from formalin-fixed and paraffin-embedded specimens successfully identified the pathogen in phaeohyphomycosis (7/18 cases, 39%), zygomycosis/pythiosis (1/32 cases, 3%), and other nonpigmented fungal infections (3/3 cases, 100%). Zygomycosis and phaeohyphomycosis were the most common forms of fungal rhinitis found in Florida horses.
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Affiliation(s)
- Sunil Nivrutti More
- 1 Department of Comparative, Diagnostic and Population Medicine, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA
| | - Oscar Hernandez
- 1 Department of Comparative, Diagnostic and Population Medicine, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA
| | - William L Castleman
- 1 Department of Comparative, Diagnostic and Population Medicine, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA
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13
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Jensen GM. The care and feeding of a commercial liposomal product: liposomal amphotericin B (AmBisome ®). J Liposome Res 2018; 27:173-179. [PMID: 28967274 DOI: 10.1080/08982104.2017.1380664] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AmBisome (liposomal amphotericin B) is among the earliest approved liposomal therapeutics, and has been in commercial use since the early 1990s. This review provides examples of non-clinical, regulatory, clinical label expansion, adverse event management, and supply chain control reflecting the real world challenges of a commercial liposomal therapeutic. We review examples of post-approval clinical development in severe lung infections, development of US and European guidance documents around liposomal therapeutics, the creation of a suitable placebo for blinded clinical trials, response to findings of a possible new category of adverse event (what turned out to be pseudohyperphosphatemia), challenges in handling the finished product in a setting with high risk of exposure of the product to temperatures outside of the established label storage conditions, and elements of continuingly increased aseptic processing requirements for manufacturing.
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14
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Schwartz S, Kontoyiannis DP, Harrison T, Ruhnke M. Advances in the diagnosis and treatment of fungal infections of the CNS. Lancet Neurol 2018; 17:362-372. [PMID: 29477506 DOI: 10.1016/s1474-4422(18)30030-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 12/16/2022]
Abstract
Fungal infections of the CNS are challenging to treat and their optimal management requires knowledge of their epidemiology, host characteristics, diagnostic criteria, and therapeutic options. Aspergillus and Cryptococcus species predominate among fungal infections of the CNS. Most of these fungi are ubiquitous, but some have restricted geographical distribution. Fungal infections of the CNS usually originate from primary sites outside the CNS (eg, fungal pneumonia) or occur after inoculation (eg, invasive procedures). Most patients with these infections have immunodeficiencies, but immunocompetent individuals can also be infected through heavy exposure. The infecting fungi can be grouped into moulds, yeasts, and dimorphic fungi. Substantial progress has been made with new diagnostic approaches and the introduction of novel antifungal drugs, but fungal infections of the CNS are frequently lethal because of diagnostic delays, impaired drug penetration, resistance to antifungal treatments, and inadequate restoration of immune function. To improve outcomes, future research should advance diagnostic methods (eg, molecular detection and fungus identification), develop antifungal compounds with enhanced CNS-directed efficacy, and further investigate crucial host defence mechanisms.
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Affiliation(s)
- Stefan Schwartz
- Medical Department, Division of Haematology, Oncology and Tumour Immunology, Charité, Berlin, Germany.
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Harrison
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Markus Ruhnke
- Department of Haematology and Oncology, Paracelsus-Hospital, Osnabrück, Germany
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15
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Gade L, Hurst S, Balajee SA, Lockhart SR, Litvintseva AP. Detection of mucormycetes and other pathogenic fungi in formalin fixed paraffin embedded and fresh tissues using the extended region of 28S rDNA. Med Mycol 2018; 55:385-395. [PMID: 27630252 DOI: 10.1093/mmy/myw083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/11/2016] [Indexed: 01/04/2023] Open
Abstract
Molecular methods of detection based on DNA-sequencing of the internal transcribed spacer 1 and 2 (ITS1 and ITS2) or 5΄ end region of 28S (D1-D2 region) of ribosomal RNA gene (rDNA) have been used extensively for molecular identification and detection of fungal infections. However, these regions are not always informative for identification of mucormycetes and other rare fungal pathogens as they often contain large introns, heterogenic regions, and/or cannot be PCR-amplified using broad range fungal PCR primers. In addition, because of the difficulties of recovering intact fungal DNA from human specimens, smaller regions of DNA are more useful for the direct detection of fungal DNA in tissues and fluids. In this study, we investigated the utility of 12F/13R PCR primers targeting a 200-230 bp region of the extended 28S region of rDNA for molecular identification of fungal DNA in formalin fixed paraffin embedded tissues and other clinical specimens. We demonstrated that this region can be successfully used for identification of all genera and some species of clinically relevant mucormycetes, as well as other medically important fungi, such as Aspergillus, Fusarium, Coccidioides, and Cryptococcus. We also demonstrated that PCR amplification and direct sequencing of the extended 28S region of rDNA was more sensitive compared to targeting the ITS2 region, as we were able to detect and identify mucormycetes and other fungal pathogens in tissues from patients with histopathological and/or culture evidence of fungal infections that were negative with PCR using ITS-specific primers.
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Affiliation(s)
- Lalitha Gade
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Steven Hurst
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - S Arunmozhi Balajee
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Shawn R Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA
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16
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Credle JJ, Itoh CY, Yuan T, Sharma R, Scott ER, Workman RE, Fan Y, Housseau F, Llosa NJ, Bell WR, Miller H, Zhang SX, Timp W, Larman HB. Multiplexed analysis of fixed tissue RNA using Ligation in situ Hybridization. Nucleic Acids Res 2017; 45:e128. [PMID: 28854731 PMCID: PMC5737328 DOI: 10.1093/nar/gkx471] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 05/12/2017] [Indexed: 12/26/2022] Open
Abstract
Clinical tissues are prepared for histological analysis and long-term storage via formalin fixation and paraffin embedding (FFPE). The FFPE process results in fragmentation and chemical modification of RNA, rendering it less suitable for analysis by techniques that rely on reverse transcription (RT) such as RT-qPCR and RNA-Seq. Here we describe a broadly applicable technique called ‘Ligation in situ Hybridization’ (‘LISH’), which is an alternative methodology for the analysis of FFPE RNA. LISH utilizes the T4 RNA Ligase 2 to efficiently join adjacent chimeric RNA–DNA probe pairs hybridized in situ on fixed RNA target sequences. Subsequent treatment with RNase H releases RNA-templated ligation products into solution for downstream analysis. We demonstrate several unique advantages of LISH-based assays using patient-derived FFPE tissue. These include >100-plex capability, compatibility with common histochemical stains and suitability for analysis of decade-old materials and exceedingly small microdissected tissue fragments. High-throughput DNA sequencing modalities, including single molecule sequencing, can be used to analyze ligation products from complex panels of LISH probes (‘LISH-seq’), which can be amplified efficiently and with negligible bias. LISH analysis of FFPE RNA is a novel methodology with broad applications that range from multiplexed gene expression analysis to the sensitive detection of infectious organisms.
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Affiliation(s)
- Joel J Credle
- Division of Immunology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Christopher Y Itoh
- Division of Immunology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Tiezheng Yuan
- Division of Immunology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Rajni Sharma
- Division of Immunology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Erick R Scott
- Department of Genetics & Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY 10078, USA
| | - Rachael E Workman
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Yunfan Fan
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Franck Housseau
- Sidney Kimmel Comprehensive Cancer Center, Department of Oncology, and the Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Nicolas J Llosa
- Sidney Kimmel Comprehensive Cancer Center, Department of Oncology, and the Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - W Robert Bell
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Heather Miller
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Sean X Zhang
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Microbiology Laboratory, Johns Hopkins Hospital, Johns Hopkins Medical Institutes, Baltimore, MD 21287, USA
| | - Winston Timp
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - H Benjamin Larman
- Division of Immunology, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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17
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Abstract
In mid-September 2012, the largest healthcare-associated outbreak in U.S. history began. Before it was over, 751 patients were reported with fungal meningitis, stroke, spinal or paraspinal infection, or peripheral osteoarticular infection, and 64 (8.5%) died. Most patients had undergone epidural injection, and a few osteoarticular injection, of methylprednisolone acetate that had been manufactured at the New England Compounding Center (NECC). The offending pathogen in most cases was Exserohilum rostratum, a brown-black soil organism that previously was a rare cause of human infection. Three lots of methylprednisolone were contaminated with mold at NECC; the mold from unopened bottles of methylprednisolone was identical by whole-genome sequencing to the mold that was isolated from ill patients. Early cases manifested as meningitis, some patients suffered posterior circulation strokes, and later cases were more likely to present with localized infection at the injection site, including epidural abscess or phlegmon, vertebral diskitis or osteomyelitis, and arachnoiditis with intradural involvement of nerve roots. Many patients with spinal or paraspinal infection required surgical intervention. Recommendations for treatment evolved over the first few weeks of the outbreak. Initially, combination therapy with liposomal amphotericin B and voriconazole was recommended for all patients; later, combination therapy was recommended only for those who were most ill, and voriconazole monotherapy was recommended for most patients. Among those patients who continued antifungal therapy for at least 6 months, outcomes for most appeared to be successful, although a few patients remain on therapy.
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18
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Mathur G, Yadav K, Ford B, Schafer IJ, Basavaraju SV, Knust B, Shieh WJ, Hill S, Locke GD, Quinlisk P, Brown S, Gibbons A, Cannon D, Kuehnert M, Nichol ST, Rollin PE, Ströher U, Miller R. High clinical suspicion of donor-derived disease leads to timely recognition and early intervention to treat solid organ transplant-transmitted lymphocytic choriomeningitis virus. Transpl Infect Dis 2017; 19. [PMID: 28423464 DOI: 10.1111/tid.12707] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 01/03/2017] [Accepted: 01/09/2017] [Indexed: 11/26/2022]
Abstract
Despite careful donor screening, unexpected donor-derived infections continue to occur in organ transplant recipients (OTRs). Lymphocytic choriomeningitis virus (LCMV) is one such transplant-transmitted infection that in previous reports has resulted in a high mortality among the affected OTRs. We report a LCMV case cluster that occurred 3 weeks post-transplant in three OTRs who received allografts from a common organ donor in March 2013. Following confirmation of LCMV infection at Centers for Disease Control and Prevention, immunosuppression was promptly reduced and ribavirin and/or intravenous immunoglobulin therapy were initiated in OTRs. The liver recipient died, but right kidney recipients survived without significant sequelae and left kidney recipient survived acute LCMV infection with residual mental status deficit. Our series highlights how early recognition led to prompt therapeutic intervention, which may have contributed to more favorable outcome in the kidney transplant recipients.
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Affiliation(s)
- Gagan Mathur
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kunal Yadav
- Department of Internal Medicine-Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bradley Ford
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ilana J Schafer
- Viral Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sridhar V Basavaraju
- Office of Blood, Organ, and Other Tissue Safety, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Barbara Knust
- Viral Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wun-Ju Shieh
- Infectious Disease Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sam Hill
- Organ Donation Department, Iowa Donor Network, North Liberty, IA, USA
| | - Garret D Locke
- Compliance & Quality Systems, Iowa Lions Eye Bank, Iowa City, IA, USA
| | - Patricia Quinlisk
- State Health Department, Iowa Department of Public Health, Des Moines, IA, USA
| | - Shelley Brown
- Viral Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ardith Gibbons
- Viral Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Deborah Cannon
- Viral Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Matthew Kuehnert
- Office of Blood, Organ, and Other Tissue Safety, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stuart T Nichol
- Viral Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Pierre E Rollin
- Viral Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ute Ströher
- Viral Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rachel Miller
- Department of Internal Medicine-Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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19
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The Carbohydrate Lectin Receptor Dectin-1 Mediates the Immune Response to Exserohilum rostratum. Infect Immun 2017; 85:IAI.00903-16. [PMID: 28031265 DOI: 10.1128/iai.00903-16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 12/22/2016] [Indexed: 12/16/2022] Open
Abstract
Dematiaceous molds are found ubiquitously in the environment and cause a wide spectrum of human disease, including infections associated with high rates of mortality. Despite this, the mechanism of the innate immune response has been less well studied, although it is key in the clearance of fungal pathogens. Here, we focus on Exserohilum rostratum, a dematiaceous mold that caused 753 infections during a multistate outbreak due to injection of contaminated methylprednisolone. We show that macrophages are incapable of phagocytosing Exserohilum Despite a lack of phagocytosis, macrophage production of tumor necrosis factor alpha is triggered by hyphae but not spores and depends upon Dectin-1, a C-type lectin receptor. Dectin-1 is specifically recruited to the macrophage-hyphal interface but not the macrophage-spore interface due to differences in carbohydrate antigen expression between these two fungal forms. Corticosteroid and antifungal therapy perturb this response, resulting in decreased cytokine production. In vivo soft tissue infection in wild-type mice demonstrated that Exserohilum provokes robust neutrophilic and granulomatous inflammation capable of thwarting fungal growth. However, coadministration of methylprednisolone acetate results in robust hyphal tissue invasion and a significant reduction in immune cell recruitment. Our results suggest that Dectin-1 is crucial for macrophage recognition and the macrophage response to Exserohilum and that corticosteroids potently attenuate the immune response to this pathogen.
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Bone and Joint Infections due to Haemophilus parainfluenzae: Case Report and Review of the Literature. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2016; 2016:4503025. [PMID: 27516778 PMCID: PMC4969501 DOI: 10.1155/2016/4503025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/15/2015] [Indexed: 11/17/2022]
Abstract
Haemophilus parainfluenzae is a normal inhabitant of the human respiratory tract. However it is an increasingly recognized pathogen in invasive infections, particularly in the immunocompromised host and where there is disruption of the normal skin or mucosal barriers. We present a case of a 56-year-old female with a history of asplenia who developed H. parainfluenzae septic arthritis of the hip following an intra-articular steroid injection. We also summarize previously reported cases of bone and joint infections caused by H. parainfluenzae.
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Geng L, Xu M, Yu L, Li J, Zhou Y, Wang Y, Chen J. Risk factors and the clinical and surgical features of fungal prosthetic joint infections: A retrospective analysis of eight cases. Exp Ther Med 2016; 12:991-999. [PMID: 27446310 PMCID: PMC4950886 DOI: 10.3892/etm.2016.3353] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/01/2016] [Indexed: 12/16/2022] Open
Abstract
Fungal prosthetic joint infections (PJI) and reports of their clinical investigation are rare. In addition, there has been little evidence regarding the outcome of the two-stage exchange protocol for the treatment of fungal PJI. In order to investigate the risk factors and clinical, microbiological and pathological features of fungal PJIs, as well as the effects of the two-stage exchange protocol on their outcome, the present study analyzed eight retrospective fungal PJI cases, involving four cases affecting the hips and four affecting the knees, between May 2000 and March 2012. In all cases, a cemented spacer saturated with antimicrobials was used during the two-stage exchange protocol, and systematic antifungal agents were administrated during the interim period. The average follow-up duration was 4.4 years. Of the eight cases, six had undergone additional surgery on the infected joint prior to infection with the fungus. Following histological analyses, it was determined that the average number of polymorphonuclear cells in the three patients infected with a fungus was only <5/high power field (HPF; magnification, ×400), and that of the five patients with a hybrid infection was >5/HPF. The average Harris Hip scores or Hospital for Special Surgery knee scores were 43.6 preoperatively and 86 at the last follow-up. The two-stage exchange protocol was performed eight times in seven cases, with a failure rate of 12.5%. The remaining case was successfully treated by resection arthroplasty. The average duration of antifungal agent administration during the interim period in five of the eight cases was 1.5 months. For three of the patients, the duration of antifungal agent administration was prolonged until the c-reactive protein levels were decreased to normal. The average duration of spacer implantation into the joint was 4.3 months. The results of the present study suggested that undergoing surgery on a prosthetic joint may be a potential risk factor for the development of fungal PJI. In addition, infiltration of polymorphonuclear leukocytes into the site of the infection may not occur at the same rate as bacterial PJI. Therefore, a two-stage exchange protocol with implantation of a cement spacer saturated with antimicrobials may be considered an effective therapeutic strategy for the treatment of fungal PJI.
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Affiliation(s)
- Lei Geng
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Meng Xu
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Ligang Yu
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Jie Li
- Department of Pathology, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Yonggang Zhou
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Yan Wang
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
| | - Jiying Chen
- Department of Orthopaedics, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
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Extensive Exserohilum infection in a burn patient. JAAD Case Rep 2016; 1:188-90. [PMID: 27051726 PMCID: PMC4808727 DOI: 10.1016/j.jdcr.2015.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chowdhary A, Hagen F, Curfs-Breuker I, Madrid H, de Hoog GS, Meis JF. In Vitro Activities of Eight Antifungal Drugs against a Global Collection of Genotyped Exserohilum Isolates. Antimicrob Agents Chemother 2015; 59:6642-5. [PMID: 26239995 PMCID: PMC4576068 DOI: 10.1128/aac.01218-15] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/27/2015] [Indexed: 11/20/2022] Open
Abstract
The in vitro susceptibilities of 24 worldwide Exserohilum isolates belonging to 10 species from human and environmental sources were determined for eight antifungal drugs. The strains were characterized by internal transcribed spacer (ITS) sequencing and amplified fragment length polymorphism fingerprinting. Posaconazole had the lowest geometric mean MIC (0.16 μg/ml), followed by micafungin (0.21 μg/ml), amphotericin B (0.24 μg/ml), itraconazole (0.33 μg/ml), voriconazole (0.8 μg/ml), caspofungin (1.05 μg/ml), isavuconazole (1.38 μg/ml), and fluconazole (15.6 μg/ml).
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Affiliation(s)
- Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Ilse Curfs-Breuker
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Hugo Madrid
- Center for Genomics and Bioinformatics and Medicine Faculty, Mayor University, Santiago, Chile
| | | | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
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Ashu EE, Xu J. The roles of sexual and asexual reproduction in the origin and dissemination of strains causing fungal infectious disease outbreaks. INFECTION GENETICS AND EVOLUTION 2015; 36:199-209. [PMID: 26394109 DOI: 10.1016/j.meegid.2015.09.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/16/2015] [Accepted: 09/18/2015] [Indexed: 12/15/2022]
Abstract
Sexual reproduction commonly refers to the reproductive process in which genomes from two sources are combined into a single cell through mating and then the zygote genomes are partitioned to progeny cells through meiosis. Reproduction in the absence of mating and meiosis is referred to as asexual or clonal reproduction. One major advantage of sexual reproduction is that it generates genetic variation among progeny which may allow for faster adaptation of the population to novel and/or stressful environments. However, adaptation to stressful or new environments can still occur through mutation, in the absence of sex. In this review, we analyzed the relative contributions of sexual and asexual reproduction in the origin and spread of strains causing fungal infectious diseases outbreaks. The necessity of sex and the ability of asexual fungi to initiate outbreaks are discussed. We propose a framework that relates the modes of reproduction to the origin and propagation of fungal disease outbreaks. Our analyses suggest that both sexual and asexual reproduction can play critical roles in the origin of outbreak strains and that the rapid spread of outbreak strains is often accomplished through asexual expansion.
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Affiliation(s)
- Eta Ebasi Ashu
- Department of Biology, McMaster University, 1280 Main St. W, Hamilton, ON L8S 4K1, Canada
| | - Jianping Xu
- Department of Biology, McMaster University, 1280 Main St. W, Hamilton, ON L8S 4K1, Canada.
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Outbreak of fungal infections associated with contaminated methylprednisolone acetate: an update. Curr Infect Dis Rep 2014; 17:441. [PMID: 25416847 DOI: 10.1007/s11908-014-0441-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In September 2012, an unprecedented outbreak of fungal infections due to preservative-free, injectable methylprednisolone acetate (MPA) was identified. Exserohilum rostratum was quickly identified as the predominant organism involved in disease cases. Prior to this outbreak, little was known about the pathogenesis, treatment, and prognosis of infections due to this unusual brown-black mold. Almost 2 years after the onset of this outbreak, numerous epidemiologic and basic science studies have provided some guidance in understanding the epidemiology, clinical findings, diagnosis, and treatment of patients exposed to the contaminated medication. Additionally, this outbreak has directly led to the passage of legislation supporting increased regulation in the industry of pharmaceutical compounding. Many unanswered questions, particularly surrounding the long-term prognosis and outcomes for affected patients remain. However, it is clear that a strong relationship between clinicians caring for patients and public health as well as a rapid, effective public health response was critical in preventing additional cases of disease.
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Chowdhary A, Perfect J, de Hoog GS. Black Molds and Melanized Yeasts Pathogenic to Humans. Cold Spring Harb Perspect Med 2014; 5:a019570. [PMID: 25384772 DOI: 10.1101/cshperspect.a019570] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A review is given of melanized fungi involved in human infection, including species forming budding cells and strictly filamentous representatives. Classically, they are known as "phaeoid" or "dematiaceous" fungi, and, today, agents are recognized to belong to seven orders of fungi, of which the Chaetothyriales and Pleosporales are the most important. Infections range from cutaneous or pulmonary colonization to systemic or disseminated invasion. Subcutaneous involvement, either primary or after dissemination, may lead to host tissue proliferation of dermis or epidermis. Particularly in the Chaetothyriales, subcutaneous and systemic infections may occur in otherwise apparently healthy individuals. Infections are mostly chronic and require extended antifungal therapy and/or surgery.
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Affiliation(s)
- Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110 007, India
| | - John Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center Durham, North Carolina 27710
| | - G Sybren de Hoog
- CBS-KNAW Fungal Biodiversity Centre, 3508 AD Utrecht, The Netherlands
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Whole-genome analysis of Exserohilum rostratum from an outbreak of fungal meningitis and other infections. J Clin Microbiol 2014; 52:3216-22. [PMID: 24951807 DOI: 10.1128/jcm.00936-14] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Exserohilum rostratum was the cause of most cases of fungal meningitis and other infections associated with the injection of contaminated methylprednisolone acetate produced by the New England Compounding Center (NECC). Until this outbreak, very few human cases of Exserohilum infection had been reported, and very little was known about this dematiaceous fungus, which usually infects plants. Here, we report using whole-genome sequencing (WGS) for the detection of single nucleotide polymorphisms (SNPs) and phylogenetic analysis to investigate the molecular origin of the outbreak using 22 isolates of E. rostratum retrieved from 19 case patients with meningitis or epidural/spinal abscesses, 6 isolates from contaminated NECC vials, and 7 isolates unrelated to the outbreak. Our analysis indicates that all 28 isolates associated with the outbreak had nearly identical genomes of 33.8 Mb. A total of 8 SNPs were detected among the outbreak genomes, with no more than 2 SNPs separating any 2 of the 28 genomes. The outbreak genomes were separated from the next most closely related control strain by ∼136,000 SNPs. We also observed significant genomic variability among strains unrelated to the outbreak, which may suggest the possibility of cryptic speciation in E. rostratum.
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Rift valley Fever virus encephalitis is associated with an ineffective systemic immune response and activated T cell infiltration into the CNS in an immunocompetent mouse model. PLoS Negl Trop Dis 2014; 8:e2874. [PMID: 24922480 PMCID: PMC4055548 DOI: 10.1371/journal.pntd.0002874] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 04/04/2014] [Indexed: 01/01/2023] Open
Abstract
Background Rift Valley fever virus (RVFV) causes outbreaks of severe disease in livestock and humans throughout Africa and the Arabian Peninsula. In people, RVFV generally causes a self-limiting febrile illness but in a subset of individuals, it progresses to more serious disease. One manifestation is a delayed-onset encephalitis that can be fatal or leave the afflicted with long-term neurologic sequelae. In order to design targeted interventions, the basic pathogenesis of RVFV encephalitis must be better understood. Methodology/Principal Findings To characterize the host immune responses and viral kinetics associated with fatal and nonfatal infections, mice were infected with an attenuated RVFV lacking NSs (ΔNSs) that causes lethal disease only when administered intranasally (IN). Following IN infection, C57BL/6 mice developed severe neurologic disease and succumbed 7–9 days post-infection. In contrast, inoculation of ΔNSs virus subcutaneously in the footpad (FP) resulted in a subclinical infection characterized by a robust immune response with rapid antibody production and strong T cell responses. IN-inoculated mice had delayed antibody responses and failed to clear virus from the periphery. Severe neurological signs and obtundation characterized end stage-disease in IN-inoculated mice, and within the CNS, the development of peak virus RNA loads coincided with strong proinflammatory responses and infiltration of activated T cells. Interestingly, depletion of T cells did not significantly alter survival, suggesting that neurologic disease is not a by-product of an aberrant immune response. Conclusions/Significance Comparison of fatal (IN-inoculated) and nonfatal (FP-inoculated) ΔNSs RVFV infections in the mouse model highlighted the role of the host immune response in controlling viral replication and therefore determining clinical outcome. There was no evidence to suggest that neurologic disease is immune-mediated in RVFV infection. These results provide important insights for the future design of vaccines and therapeutic options. Rift Valley fever virus (RVFV) is a mosquito-borne virus that causes severe disease in people and livestock throughout Africa and the Arabian Peninsula. Human disease is usually self-limiting, but a small proportion of individuals develop fatal encephalitis. The role of the host immune response in determining disease outcome is largely unknown. In order to compare the quality and character of immune responses in nonfatal and fatal cases, we used an attenuated RVFV to inoculate mice by two routes. Subcutaneous inoculation resulted in a subclinical systemic infection that was rapidly cleared due to a robust adaptive response. In contrast, intranasal inoculation stimulated weaker immune responses that failed to control virus replication and culminated in uniformly fatal encephalitis. With many encephalitic viruses, the onset of disease is mediated by changes in blood brain barrier permeability and often, subsequent injury to the CNS by an uncontrolled immune response. However, our results suggest that development of RVFV disease does not depend on either mechanism, but rather results from direct virus-mediated damage in the CNS. Future therapeutic drug design should take into account all possible routes of virus exposure as well as the role of therapies that boost the adaptive response to better combat disease.
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Farmakiotis D, Shirazi F, Zhao Y, Saad PJ, Albert ND, Roilides E, Walsh TJ, Perlin DS, Kontoyiannis DP. Methylprednisolone enhances the growth of Exserohilum rostratum in vitro, attenuates spontaneous apoptosis, and increases mortality rates in immunocompetent Drosophila flies. J Infect Dis 2014; 210:1471-5. [PMID: 24837401 DOI: 10.1093/infdis/jiu289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
High concentrations of methylprednisolone (0.32 mg/mL) accelerated growth and attenuated spontaneous apoptosis of Exserohilum rostratum in vitro. Injection of E. rostratum conidia preexposed to 0.32 mg/mL of methylprednisolone for 7 days in immunocompetent flies led to increased mortality and a higher fungal burden. Exposure to methylprednisolone could enhance the virulence of E. rostratum.
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Affiliation(s)
| | - Fazal Shirazi
- The University of Texas M.D Anderson Cancer Center, Houston
| | - Yanan Zhao
- Public Health Research Institute Center, New Jersey Medical School, Rutgers-The State University of New Jersey, Newark
| | - Peguy J Saad
- The University of Texas M.D Anderson Cancer Center, Houston
| | | | | | - Thomas J Walsh
- New York-Presbyterian/Weill Cornell Medical Center, New York City
| | - David S Perlin
- Public Health Research Institute Center, New Jersey Medical School, Rutgers-The State University of New Jersey, Newark
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Abstract
PURPOSE OF REVIEW The recent outbreak of fungal meningitis related to contaminated methylprednisolone acetate injections represents an important cause of morbidity and continues to be a significant public health problem in the United States. RECENT FINDINGS As of August 2013, there have been 749 cases and 63 deaths in 20 states associated with epidemic fungal meningitis, most of these because of Exserohilum rostratum. Clinical experience in managing these cases has grown dramatically in the last several months; most patients require at least 6 months of antifungal therapy for complicated disease. Most patients are treated with voriconazole, with or without liposomal amphotericin B, for central nervous system and paraspinal complications of the disease. For disease involving the sacroiliac and peripheral joints, voriconazole alone has been preferred. MRI spine imaging has identified several cases of asymptomatic disease, suggesting an aggressive diagnostic approach to exposed asymptomatic patients. Mortality remains low (<10%), but morbidity relating to persistent symptoms and treatment-associated toxicity is high. SUMMARY The ongoing fungal meningitis epidemic demonstrates an important achievement for the public health community. Important questions remain relating to the diagnosis, management, and long-term outcomes of these patients. Important research questions pertaining to specific risks influencing disease manifestations remain unanswered.
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Chowdhary A, Meis J, Guarro J, de Hoog G, Kathuria S, Arendrup M, Arikan-Akdagli S, Akova M, Boekhout T, Caira M, Guinea J, Chakrabarti A, Dannaoui E, van Diepeningen A, Freiberger T, Groll A, Hope W, Johnson E, Lackner M, Lagrou K, Lanternier F, Lass-Flörl C, Lortholary O, Meletiadis J, Muñoz P, Pagano L, Petrikkos G, Richardson M, Roilides E, Skiada A, Tortorano A, Ullmann A, Verweij P, Cornely O, Cuenca-Estrella M. ESCMID and ECMM joint clinical guidelines for the diagnosis and management of systemic phaeohyphomycosis: diseases caused by black fungi. Clin Microbiol Infect 2014; 20 Suppl 3:47-75. [DOI: 10.1111/1469-0691.12515] [Citation(s) in RCA: 216] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 12/13/2013] [Accepted: 12/16/2013] [Indexed: 11/28/2022]
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Bhagavatula S, Vale L, Evans J, Carpenter C, Barnes RA. Scedosporium prolificans osteomyelitis following penetrating injury: A case report. Med Mycol Case Rep 2014; 4:26-9. [PMID: 24855598 PMCID: PMC4024514 DOI: 10.1016/j.mmcr.2014.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/07/2014] [Accepted: 03/12/2014] [Indexed: 11/30/2022] Open
Abstract
Scedosporium prolificans are opportunistic moulds that can cause mycetoma following penetrating injuries. This fungus is more virulent than other species and treatment options are limited. Here we describe the first known case in the UK of S. prolificans osteomyelitis, in a 4 year old following penetrating injury. Successful outcome with limb salvage and foot function is achieved after repeated surgical debridement, and combination chemotherapy with voriconazole/terbinafine.
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Affiliation(s)
- S Bhagavatula
- Department of Microbiology, University Hospital of Wales, Cardiff, United Kingdom
| | - L Vale
- Department of Microbiology, University Hospital of Wales, Cardiff, United Kingdom
| | - J Evans
- Department of Paediatrics and Child Health, University Hospital of Wales, Cardiff, United Kingdom
| | - C Carpenter
- Department of Paediatric Orthopedics, University Hospital of Wales, Cardiff, United Kingdom
| | - R A Barnes
- Department of Microbiology, University Hospital of Wales, Cardiff, United Kingdom
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Kourbeti IS, Mylonakis E. Fungal central nervous system infections: prevalence and diagnosis. Expert Rev Anti Infect Ther 2014; 12:265-73. [PMID: 24392732 DOI: 10.1586/14787210.2014.874282] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fungal infections of the central nervous system (CNS) are rare but they pose a significant challenge. Their prevalence spans a wide array of hosts including immunosuppressed and immunocompetent individuals, patients undergoing neurosurgical procedures and those carrying implantable CNS devices. Cryptococcus neoformans and Aspergillus spp. remain the most common pathogens. Magnetic resonance imaging can help localize the lesions, but diagnosis is challenging since invasive procedures may be needed for the retrieval of tissue, especially in cases of fungal abscesses. Antigen and antibody tests are available and approved for use in the cerebrospinal fluid (CSF). PCR-based techniques are promising but they are not validated for use in the CSF. This review provides an overview on the differential diagnosis of the fungal CNS disease based on the host and the clinical syndrome and suggests the optimal use of diagnostic techniques. It also summarizes the emergence of Cryptococcus gatti and an unanticipated outbreak caused by Exserohilum rostratum.
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Affiliation(s)
- Irene S Kourbeti
- Infectious Disease Division, Alpert Medical School and Brown University, Rhode Island Hospital, RI, USA
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Smith RM, Schaefer MK, Kainer MA, Wise M, Finks J, Duwve J, Fontaine E, Chu A, Carothers B, Reilly A, Fiedler J, Wiese AD, Feaster C, Gibson L, Griese S, Purfield A, Cleveland AA, Benedict K, Harris JR, Brandt ME, Blau D, Jernigan J, Weber JT, Park BJ. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med 2013; 369:1598-609. [PMID: 23252499 DOI: 10.1056/nejmoa1213978] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fungal infections are rare complications of injections for treatment of chronic pain. In September 2012, we initiated an investigation into fungal infections associated with injections of preservative-free methylprednisolone acetate that was purchased from a single compounding pharmacy. METHODS Three lots of methylprednisolone acetate were recalled by the pharmacy; examination of unopened vials later revealed fungus. Notification of all persons potentially exposed to implicated methylprednisolone acetate was conducted by federal, state, and local public health officials and by staff at clinical facilities that administered the drug. We collected clinical data on standardized case-report forms, and we tested for the presence of fungi in isolates and specimens by examining cultures and performing polymerase-chain-reaction assays and histopathological and immunohistochemical testing. RESULTS By October 19, 2012, more than 99% of 13,534 potentially exposed persons had been contacted. As of July 1, 2013, there were 749 reported cases of infection in 20 states, with 61 deaths (8%). Laboratory evidence of Exserohilum rostratum was present in specimens from 153 case patients (20%). Additional data were available for 728 case patients (97%); 229 of these patients (31%) had meningitis with no other documented infection. Case patients had received a median of 1 injection (range, 1 to 6) of implicated methylprednisolone acetate. The median age of the patients was 64 years (range, 15 to 97), and the median incubation period (the number of days from the last injection to the date of the first diagnosis) was 47 days (range, 0 to 249); 40 patients (5%) had a stroke. CONCLUSIONS Analysis of data from a large, multistate outbreak of fungal infections showed substantial morbidity and mortality. The infections were associated with injection of a contaminated glucocorticoid medication from a single compounding pharmacy. Rapid public health actions included prompt recall of the implicated product, notification of exposed persons, and early outreach to clinicians.
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Affiliation(s)
- Rachel M Smith
- From the Epidemic Intelligence Service, Scientific Education and Professional Development Program Office (R.M.S., S.G., A.P.), Division of Foodborne, Waterborne, and Environmental Diseases (R.M.S., A.P., A.A.C., K.B., J.R.H., M.E.B., B.J.P.), Division of Healthcare Quality Promotion (M.K.S., M.W., J.J., J.T.W.), and Division of High-Consequence Pathogens and Pathology (D.B.), Centers for Disease Control and Prevention, Atlanta; the Tennessee Department of Health, Nashville (M.A.K., A.D.W.); the Michigan Department of Community Health, Bureau of Epidemiology, Lansing (J. Finks, J. Fiedler); the Indiana State Department of Health, Indianapolis (J.D., C.F.); the Virginia Department of Health, Richmond (E.F., L.G.); the Maryland Department of Health and Mental Hygiene, Baltimore (A.C.); the New Jersey Department of Health, Trenton (B.C.); the Florida Department of Health, Tallahassee (A.R.); and the North Carolina Division of Public Health, Raleigh (S.G.)
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Chiller TM, Roy M, Nguyen D, Guh A, Malani AN, Latham R, Peglow S, Kerkering T, Kaufman D, McFadden J, Collins J, Kainer M, Duwve J, Trump D, Blackmore C, Tan C, Cleveland AA, MacCannell T, Muehlenbachs A, Zaki SR, Brandt ME, Jernigan JA. Clinical findings for fungal infections caused by methylprednisolone injections. N Engl J Med 2013; 369:1610-9. [PMID: 24152260 DOI: 10.1056/nejmoa1304879] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Since September 18, 2012, public health officials have been investigating a large outbreak of fungal meningitis and other infections in patients who received epidural, paraspinal, or joint injections with contaminated lots of methylprednisolone acetate. Little is known about infections caused by Exserohilum rostratum, the predominant outbreak-associated pathogen. We describe the early clinical course of outbreak-associated infections. METHODS We reviewed medical records for outbreak cases reported to the Centers for Disease Control and Prevention before November 19, 2012, from the six states with the most reported cases (Florida, Indiana, Michigan, New Jersey, Tennessee, and Virginia). Polymerase-chain-reaction assays and immunohistochemical testing were performed on clinical isolates and tissue specimens for pathogen identification. RESULTS Of 328 patients without peripheral-joint infection who were included in this investigation, 265 (81%) had central nervous system (CNS) infection and 63 (19%) had non-CNS infections only. Laboratory evidence of E. rostratum was found in 96 of 268 patients (36%) for whom samples were available. Among patients with CNS infections, strokes were associated with an increased severity of abnormalities in cerebrospinal fluid (P<0.001). Non-CNS infections were more frequent later in the course of the outbreak (median interval from last injection to diagnosis, 39 days for epidural abscess and 21 days for stroke; P<0.001), and such infections developed in patients with and in those without meningitis. CONCLUSIONS The initial clinical findings from this outbreak suggest that fungal infections caused by epidural and paraspinal injection of a contaminated glucocorticoid product can result in a broad spectrum of clinical disease, reflecting possible variations in the pathogenic mechanism and in host and exposure risk factors. (Funded by the Centers for Disease Control and Prevention.).
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Affiliation(s)
- Tom M Chiller
- The authors' affiliations are listed in the Appendix
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36
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Lockhart SR, Pham CD, Gade L, Iqbal N, Scheel CM, Cleveland AA, Whitney AM, Noble-Wang J, Chiller TM, Park BJ, Litvintseva AP, Brandt ME. Preliminary laboratory report of fungal infections associated with contaminated methylprednisolone injections. J Clin Microbiol 2013; 51:2654-61. [PMID: 23761142 PMCID: PMC3719655 DOI: 10.1128/jcm.01000-13] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 06/03/2013] [Indexed: 11/20/2022] Open
Abstract
In September 2012, the Centers for Disease Control and Prevention (CDC) initiated an outbreak investigation of fungal infections linked to injection of contaminated methylprednisolone acetate (MPA). Between 2 October 2012 and 14 February 2013, the CDC laboratory received 799 fungal isolates or human specimens, including cerebrospinal fluid (CSF), synovial fluid, and abscess tissue, from 469 case patients in 19 states. A novel broad-range PCR assay and DNA sequencing were used to evaluate these specimens. Although Aspergillus fumigatus was recovered from the index case, Exserohilum rostratum was the primary pathogen in this outbreak and was also confirmed from unopened MPA vials. Exserohilum rostratum was detected or confirmed in 191 specimens or isolates from 150 case patients, primarily from Michigan (n=67 patients), Tennessee (n=26), Virginia (n=20), and Indiana (n=16). Positive specimens from Michigan were primarily abscess tissues, while positive specimens from Tennessee, Virginia, and Indiana were primarily CSF. E. rostratum antifungal susceptibility MIC50 and MIC90 values were determined for voriconazole (1 and 2 μg/ml, respectively), itraconazole (0.5 and 1 μg/ml), posaconazole (0.5 and 1 μg/ml), isavuconazole (4 and 4 μg/ml), and amphotericin B (0.25 and 0.5 μg/ml). Thirteen other mold species were identified among case patients, and four other fungal genera were isolated from the implicated MPA vials. The clinical significance of these other fungal species remains under investigation. The laboratory response provided significant support to case confirmation, enabled linkage between clinical isolates and injected vials of MPA, and described significant features of the fungal agents involved in this large multistate outbreak.
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Affiliation(s)
- Shawn R Lockhart
- Mycotic Diseases Branch, National Center for Emerging, Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Feldmesser M. Fungal disease following contaminated steroid injections: Exserohilum is ready for its close-up. THE AMERICAN JOURNAL OF PATHOLOGY 2013; 183:661-4. [PMID: 23876717 DOI: 10.1016/j.ajpath.2013.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 06/28/2013] [Accepted: 06/28/2013] [Indexed: 11/25/2022]
Abstract
This Commentary highlights the article by Ritter et al. that reported the pathology associated with the recent fungal outbreak associated with contaminated methylprednisolone acetate injections.
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Affiliation(s)
- Marta Feldmesser
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
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