The values of (1,3)-β-D-glucan and galactomannan in cases of invasive fungal rhinosinusitis

Peripheral blood lymphocyte subsets combined with fungal biomarkers in the diagnosis of invasive fungal infections complicated by sepsis

OBJECTIVE

To evaluate the lymphocyte subpopulations and the levels of (1, 3)-β-d-glucan (BDG) and galactomannan (GAL) in sepsis patients with secondary invasive fungal infections (IFIs), and to investigate the association between lymphocytes and IFIs.

METHODS

A retrospective case-control study of 47 patients with sepsis complicated by IFIs, 50 sepsis patients, and 50 healthy controls was conducted. The correlation between lymphocyte subsets and BDG, GAL levels was analyzed using the Spearman correlation method, and the diagnostic efficacy of IFIs-related factors was assessed using the receiver operating characteristic curve (ROC) analysis.

RESULTS

The IFIs group exhibited significantly lower absolute lymphocyte counts (P < 0.05). The study revealed that both BDG and GAL levels were inversely correlated with the counts of total lymphocytes and CD4+ lymphocytes (BDG: R2 = 0.361, 0.283; GAL: R2 =0.257, 0.375, P < 0.05). The area under the curve (AUC) for the combined diagnostic markers was as follows: BDG and GAL alone had an AUC of 0.753; BDG and GAL in conjunction with lymphocyte count had an AUC of 0.921; and the combination of BDG, GAL, lymphocyte count, and CD4 T lymphocyte count achieved an AUC of 0.962. The sensitivities for these combinations were 80.00 %, 80.85 %, and 87.23 %, respectively, while the specificities were 60.00 %, 96.0 %, and 98.00 %, respectively.

CONCLUSIONS

The reduced absolute counts of lymphocyte subsets in patients with IFIs complicated by sepsis suggest a state of immunosuppression. The concurrent assessment of BDG, GAL, total lymphocyte count, and CD4 T lymphocyte count demonstrates high diagnostic efficacy for identifying IFIs complicated by sepsis.

Invasive fungal rhinosinusitis: current evidence and research opportunities

PURPOSE OF REVIEW

To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs.

RECENT FINDINGS

New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed.

SUMMARY

Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.

Efficacy of cleaning, disinfection, and sterilization modalities for addressing infectious drug-resistant fungi: a review

This is a timely and important review that focuses on the appropriateness of established cleaning, disinfection, and sterilization methods to safely and effectively address infectious fungal drug-resistant pathogens that can potentially contaminate reusable medical devices used in healthcare environment in order to mitigate the risk of patient infection. The release of the World Health Organization (WHO) fungal priority pathogen list (FPPL) in 2022 highlighted the public health crisis of antimicrobial resistance (AMR) in clinically relevant fungal species. Contamination of medical devices with drug-resistant fungal pathogens (including those on the FPPL) in healthcare is a rare event that is more likely to occur due to cross-transmission arising from lapses in hand hygiene practices. Established disinfection and sterilization methods decontaminate fungal pathogens on single-use and reusable medical devices; however, there are assumptions that reusable devices destined for semi-critical use are appropriately cleaned and do not harbour biofilms that may undermine the ability to effectively decontamination these type devices in healthcare. International standards dictate that manufacturer's instructions for use must provide appropriate guidance to healthcare facilities to meet safe reprocessing expectations that include addressing drug-resistant fungal pathogens. Increased environmental monitoring and vigilance surrounding fungal pathogens in healthcare is advised, including adherence to hand hygiene/aseptic practices and appropriate cleaning encompassing the simplification of reusable device features for 'ease-of-reach'. There are emereging opportunities to promote a more integrated multiactor hub approach to addressing these sophisticated challenges, including future use of artificial intelligence and machine learning for improved diagnostics, monitoring/surveillance (such as healthcare and wastewater-based epidemiology), sterility assurance, and device design. There is a knowledge gap surrounding the occurrence and potential persistence of drug-resistant fungal pathogens harboured in biofilms, particularly for ascertaining efficacy of high-level disinfection for semi-critical use devices.

Rhizopus microsporus and Mucor racemosus coinfection following COVID-19 detected by metagenomics next-generation sequencing: A case of disseminated mucormycosis

Mucormycosis is an invasive opportunistic fungal infection, which may be lethal and mostly affects patients with immunodeficiency or diabetes mellitus. Among Mucorales fungi, Rhizopus spp. is the most common cause of mucormycosis, followed by genera such as Mucor and Lichtheimia. Here we report a patient with severe COVID-19 infection who developed nasal pain, facial swelling, prominent black eschar on the nasal root. CT scan revealed pansinusitis along the maxillary, ethmoidal, and sphenoid sinuses. Mixed mold infection with Rhizopus microsporus and Mucor racemosus was detected by blood metagenomics next-generation sequencing (mNGS) and later nasal mucosa histological investigation confirmed mucormycosis. Severe COVID-19 infection led to the patient's thrombocytopenia and leukopenia. Later disseminated mucormycosis aggravated the infection and sepsis eventually resulted in death. It is the first case report of mucormycosis in which R. microsporus and M. racemosus as the etiologic agents were found simultaneously in one patient. COVID-19 infection combined with disseminated mucormycosisis can be fatal and mNGS is a fast, sensitive and accurate diagnostic method for fungi detection.

Diagnostic performance of serum galactomannan and β-D-glucan for invasive aspergillosis in suspected patients: A meta-analysis

BACKGROUND

Serum galactomannan (GM) and β-D-glucan (BG) are known markers of invasive aspergillosis (IA). The aim of this meta-analysis was to evaluate the efficiency of serum GM and BG as diagnostic markers of symptomatic IA infection and compare the performance of the combined tests with that of either test individually.

METHODS

A literature search was carried out using PubMed, Web of Science, and EMBASE databases to include relevant studies published in English up to May 2023. The quality assessment was performed using Review Manager 5.3 software. A bivariate model was applied to pool diagnostic parameters using Stata 14.0 software. We used Cochrane I2 index to assess heterogeneity and identify the potential source of heterogeneity by meta-regression. Paired t tests were used to compare the value of GM and BG for IA diagnosis when used in combination or alone.

RESULTS

Sixteen studies were eligible for inclusion in the meta-analysis. For proven or probable IA, serum GM and BG yielded a pooled sensitivity of 0.53 (95% CI 0.40-0.66) vs 0.72 (95% CI 0.61-0.81) and a pooled specificity of 0.94 (95% CI 0.91-0.97) vs 0.82 (95% CI 0.73-0.88). The area under the curve (AUC) of ROC was 0.90 (95% CI 0.87-0.92) vs 0.83 (95% CI 0.80-0.86) for all studies. The pooled sensitivity and specificity for IA diagnosis by combined GM and BG assays (GM/BG) were 0.84 (95% CI 0.69-0.86) and 0.76 (95% CI 0.69-0.81), respectively. The sensitivity of the combined GM/BG test to diagnose IA was higher than of the GM or BG test alone.

CONCLUSION

Serum GM and BG tests had a relatively high accuracy for IA diagnosis in suspected patients. The diagnostic accuracy of both assays is comparable, and the diagnostic sensitivity is further improved by the combined detection of the 2 markers.

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations

BACKGROUND

Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated.

RESULTS

A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains.

CONCLUSION

Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

The impact of COVID-19 outbreak on the incidence of acute invasive fungal rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFRS) is aggressive morbidity affecting immunocompromised patients. Coronavirus disease 2019 (COVID-19) may allow secondary fungal disease through a propensity to cause respiratory infection by affecting the immune system leading to dysregulation and reduced numbers of T lymphocytes, CD4+T, and CD8+T cells, altering the innate immunity. The aim of this study is to evaluate the incidence of acute invasive fungal rhinosinusitis (AIFRS) in COVID-19 patients.

METHODOLOGY

Data for acute invasive rhinosinusitis was obtained from the Otorhinolaryngology departments at our tertiary hospital at the period from January 2017 to December 2020. Then the risk factors of comorbid diseases and fungal types between post-COVID-19 and non-COVID-19 groups regarding the incidence of AIFRS are compared.

RESULTS

Consequently, the incidence of AIFRS showed a more significant difference (P < 0.05) in post-COVID-19 patients than in non-COVID-19 especially in immunocompromised patients, diabetic, renal, and liver dysfunction patients as well as patients with risk factors of AIFRS. The most common organisms affecting patients with AIFRS are Rhizopus oryzae, Aspergillus fumigatus, and Absidia mucor.

CONCLUSIONS

The incidence of AIFRS is markedly prominent in post-COVID-19 patients than in those of non-COVID-19, especially in immunocompromised, diabetic, renal, and liver dysfunction patients and patients with risk factors for rhinosinusitis.