Epidemiology and outcome ofScedosporium prolificansinfection, a review of 162 cases

Lomentospora prolificans synthesizes several types of melanin

Lomentospora prolificans is a filamentous fungus with a global distribution, exhibiting a particularly higher prevalence in human-impacted environments. Melanins are biological compounds with important functions that contribute to the virulence of many pathogenic fungi. Like many fungi, L. prolificans produces melanin, but little is known about its structure and composition. In the current study, we characterized L. prolificans-associated melanin using chemical, biological, biophysical, and structural techniques while also assessing the impact of inhibitors of distinct melanization pathways. Our results reveal that this pathogenic fungus produces multiple types of melanin pigments and suggest the possibility of a new type of melanin, which is synthesized together with a mixture of DHN-, DOPA-, and pyomelanin types.IMPORTANCEThis fungal species is associated with a wide spectrum of human infections, especially in immunosuppressed individuals, for whom it causes severe and debilitating illnesses with high morbidity and mortality that are compounded by its pan-resistant profile with respect to antifungal drugs. Melanin is a ubiquitous pigment among fungi with a broad range of actions that include promoting fungal virulence. Although melanin is one of the most studied virulence factors in pathogenic fungi, relatively little is known about the chemistry of this pigment in L. prolificans. These insights enhance our understanding of L. prolificans' virulence mechanisms, paving the way for potential therapeutic interventions.

Clinical significance and antifungal susceptibility profile of 103 clinical isolates of Scedosporium species complex and Lomentospora prolificans obtained from NIH patients

Reduced susceptibility to antifungals is common among members of genera Scedosporium and Lomentospora, with optimal treatments still not fully defined. In vitro antifungal susceptibility results and clinical data do not comprehensively account for the advent of new Scedosporium species identified by molecular phylogenetics. Using Clinical and Laboratory Standards Institute (CLSI) methodology, we tested a total of 103 clinical isolates obtained from patients at the NIH Clinical Center. The most frequent species were Scedosporium apiospermum (63%) and Scedosporium boydii (11%), followed by Lomentospora prolificans (7%). The novel antifungal olorofim showed the lowest MICs against all Scedosporium spp. and L. prolificans, followed by micafungin. Among the triazoles, voriconazole showed lower MICs against Scedosporium spp. Amphotericin B and posaconazole demonstrated species-specific and inter-species variable activity. Itraconazole, isavuconazole, and terbinafine had higher MIC values against Scedosporium spp. and L. prolificans. Clinical data were retrospectively reviewed for 90 isolates, of which nine patients (28 isolates) had active disease/infection and received antifungal treatment that included voriconazole or posaconazole. Five of these patients (56%) died, while three patients (33%) with chronic granulomatous disease were cured following hematopoietic cell transplantation. In 24 patients (62 isolates), the presence of the fungus was considered airway colonization. In conclusion, our data support the existence of species-specific and inter-species differences in the antifungal susceptibility patterns among members of genera Scedosporium and L. prolificans. The novel investigational antifungal olorofim may be a promising therapy. Our clinical data suggest that host status and administration of antifungal therapy most effective for each Scedosporium species complex are important determinants of outcomes.IMPORTANCEUnderstanding the epidemiology and clinical spectrum of infections caused by Scedosporium species complex and Lomentospora prolificans is integral to improving outcomes, particularly in severely ill and immunocompromised patients. In vitro antifungal susceptibility testing can provide an estimate of antifungal activity against fungal pathogens. Our study showed that species-specific and inter-species differences exist in the distribution of antifungal susceptibility patterns between Scedosporium and L. prolificans. Our clinical data also highlight that host status, along with effective antifungal therapy, plays a crucial role in determining treatment outcomes.

Clinical Significance and Therapeutic Challenges of Scedosporium spp. and Lomentospora prolificans Isolates in a Single-Center Cohort of Lung Transplant Recipients

(1) Background: Emerging fungal infections associated with Scedosporium spp. and Lomentospora prolificans (S/L) are becoming more frequent and are very difficult to treat. Our objective was to analyze the frequency and management of S/L isolates in lung transplant (LTx) recipients, the patient outcomes and in vitro antifungal sensitivity. (2) Methods: We included all patients with S/L isolation during post-transplant follow-up. Data were collected from electronic medical records. All samples were cultivated on Sabouraud Chloramphenicol agar. Isolations of S/L were submitted to in vitro susceptibility tests. (3) Results: A total of 11 (2%) of the 576 LTx recipients included had at least one isolation of S/L. Classification for the 11 cases were colonization (4; 36%) and infection (7; 65%). Five infections were pulmonary (71%) and two were disseminated (29%). S. apiospermum complex was the most frequently occurring isolation in patients with pulmonary disease while L. prolificans was the most frequent in patients with disseminated disease. Ten patients were treated. The most frequent antifungal drugs used were voriconazole (n = 8) and terbinafine (n = 6). Seven patients (70%) received more than one drug. The mortality rate associated with L. prolificans isolation was 50% for colonization and 100% for disseminated disease. (4) Conclusions: Scedosporium spp. and L. prolificans infections are associated with high morbidity and mortality rates. New diagnostic and therapeutic tools are required to reduce the impact of these infections.

American Society of Transplantation and Cellular Therapy Series: #8-Management and Prevention of Non-Aspergillus Molds in Hematopoietic Cell Transplantation Recipients

The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to create a guideline focusing on non-Aspergillus invasive molds, which are uncommon yet lethal invasive fungal diseases in the peri-hematopoietic cell transplant (HCT) period. We used a compendium-style approach by dissecting this broad, heterogeneous, and highly complex topic into a series of standalone frequently asked questions (FAQs) and tables. Adult and pediatric infectious diseases and HCT content experts developed, then answered FAQs, and finalized topics with harmonized recommendations. All the evidence for non-Aspergillus invasive mold infection is non-RCT and mostly level III, therefore there are no recommendation grades, and instead key references are provided. Through this format, this "8th" topic in the series focuses on the relevant risk factors, diagnostic considerations, prophylaxis, and treatment approaches relevant to rare mold infections in the pre- and post-transplant periods.

Fungal Pericarditis-A Systematic Review of 101 Cases

Fungal pericarditis is a rare disease but its incidence has risen in parallel with the global increase in invasive fungal infections. This systematic review analyzes data from previously reported cases of fungal pericarditis to provide an improved understanding of the etiology, clinical presentation, management, and outcomes of this rare disease. We reviewed Medline and Scopus databases from 1 January 1990 to 29 January 2024 for case reports that documented the isolation of a fungal pathogen from pericardial fluid or tissue. Of the 2330 articles screened, 101 cases met the inclusion criteria. Patients with fungal pericarditis and the involvement of at least one other organ-usually the lungs, brain, or kidney-had worse outcomes than patients with isolated pericardial disease. Immunosuppression was reported in 50% of cases and was associated with worse outcomes in adults. Patients who presented with chest pain, received adequate empiric antifungal therapy, and underwent pericardiocentesis and pericardiectomy had improved survival. The most common isolated pathogens were Candida spp., followed by Aspergillus spp. and Mucor spp., with the latter two linked to worse outcomes. Only 35% of patients received empiric antifungal medications before the causative pathogen was identified, and mortality was associated with a delay in appropriate therapy. Immunosuppression, disseminated disease, and presence of shock/multiorgan failure were additional risk factors associated with death. Fungal pericarditis carries a mortality rate of up to 50%, with nearly half of patients being immunocompromised. Clinicians frequently do not consider fungal pericarditis in the differential diagnoses, which leads to delays in treatment and poorer outcomes. Further prospective multicenter studies are urgently needed to better understand the epidemiology, improve diagnostic testing and management, and decrease unacceptably high mortality in patients with fungal pericarditis.

Epidemiology and Prognostic Factors Associated With Mold-Positive Blood Cultures: 10-Year Data From a French Prospective Surveillance Program (2012-2022)

BACKGROUND

While invasive fusariosis and lomentosporiosis are known to be associated with fungemia, overall data on mold-related fungemia are limited, hampering early management. This study aimed to describe the epidemiology of mold-positive blood cultures.

METHODS

Epidemiological and clinical data on mold-positive blood cultures from 2012 to 2022 were obtained from the RESSIF database. Pseudofungemia was excluded using modified Duthie and Denning criteria. Univariable and multivariable Firth logistical regression was used to study factors associated with 90-day mortality.

RESULTS

Fusarium spp accounted for 67.5% of the 80 events, involving predominantly Fusarium fujikuroi spp complex (FFSC), Neocosmospora spp, and Fusarium oxysporum spp complex (FOSC). Lomentospora prolificans was the second most frequent (10%), followed by Trichoderma spp, Aspergillus spp, and Mucorales (5% each).Most patients had a history of hematological malignancy (HM) (70%). Forty-three percent had undergone allogeneic hematopoietic stem cell transplantation. Cutaneous and pulmonary lesions were common (43% each). Median time to blood culture positivity was 72 hours.HM and neutropenia were commonly reported in patients with FFSC, Neocosmospora spp, and L. prolificans fungemia. Pulmonary lesions were frequent in cases of L. prolificans fungemia. Patients with gastrointestinal conditions were frequently diagnosed with FOSC molds. HM (75%), particularly acute myeloblastic leukemia, was frequent in patients with Aspergillus spp fungemia. All patients with Trichoderma spp fungemia were exposed to corticosteroids.Day 90 mortality was 53%. Independent predictive factors of day 90 mortality included L. prolificans (odds ratio [OR], 33.3), Aspergillus spp fungemia (OR, 14.2), and corticosteroid exposure (OR, 7.85).

CONCLUSIONS

Underlying conditions and clinical presentation vary between genera and could be considered to guide early management.

Diagnosis and management of invasive fungal infections due to non-Aspergillus moulds

Invasive fungal infection (IFI) due to moulds other than Aspergillus are a significant cause of morbidity and mortality. Non-Aspergillus mould (NAM) infections appear to be on the increase due to an ever-expanding population of immunocompromised hosts. In this review, Mucorales, Scedosporium species, Lomentospora prolificans and Fusarium species are examined in detail, and the microbiology, risk factors, diagnosis and treatment of emerging NAMs such as Paecilomyces variotti, Purpureocillium lilacinum and Rasamsonia are summarized. The challenges in diagnosis are emphasized and the emerging importance of molecular methods is discussed. Treatment of IFI due to NAMs is a multi-pronged and multi-disciplinary approach. Surgery, correction of underlying risk factors, and augmentation of the host immune response are as important as antifungal therapy. Many of these NAMs are intrinsically resistant to the currently licensed antifungal agents, so selection of therapy needs to be guided by susceptibility testing. There are new antifungal agents in development, and these have the potential to improve the efficacy and safety of antifungal treatment in the future. Ongoing research is required to fully delineate the epidemiology of NAM infections, and to develop better diagnostic tools and treatments so that outcomes from these infections can continue to improve.

Dematiaceous Molds

Dematiaceous molds are darkly pigmented environmental molds found worldwide, especially prevalent in tropical and subtropical regions. Common genera include Bipolaris, Cladophialophora, Exophiala, and Alternaria. They cause disease in both immunocompetent and immunocompromised individuals, presenting as cutaneous infections, allergic sinusitis, pneumonia, and, rarely, disseminated infections. Contaminated medical products have also led to fungal meningitis outbreaks. Treatment typically involves itraconazole, voriconazole, or posaconazole, along with source control and reduction in immunosuppression, if possible. Newer antifungals may have a role in treatment. Mortality is high in disseminated disease, especially with Lomentospora prolificans in immunocompromised individuals, prompting global efforts to improve diagnostics and treatments.

Systemic Scedosporium apiospermum Infection Affecting Multiple Sites After Near-Drowning: A Case Report

Scedosporium apiospermum (S. apiospermum) can cause fungal infections in near-drowning victims, and an increasing number of cases have been reported. However, cases of bone and joint infections caused by S. apiospermum are rare. In this case, a 35-year-old otherwise healthy Chinese female presented with aspiration pneumonia and knee arthritis after accidentally falling into sewage and near-drowning and underwent macrogenomic second-generation sequencing of arthrocentesis fluid, which showed S. apiospermum. However, new lesions involving the hip joint and spine continued to develop under voriconazole monotherapy. The patient was treated with voriconazole combined with amphotericin B cholesterol sulfate lipid complex for 30 consecutive days. The patient's symptoms improved significantly. This case highlights the robust invasiveness of S. apiospermum and the extensive spread of infection, underscoring the importance of prompt diagnosis and treatment. A combined therapeutic approach may offer a safe and efficacious option for managing S. apiospermum infection.

Two cases of fungemia due to Lomentospora prolificans in haematological patients with different outcome

Lomentospora prolificans is an uncommon cause of invasive fungal disease, but it is associated with high mortality because it is difficult to treat. Most of severe cases are produced in immunossupressed patients, especially in those with neutropenia and/or hematological malignancies. Resistance to the majority of antifungal agents can be still observed. Here we report two cases of L. prolificans fungemia with different outcome, since in one of these patients treatment with one of the new antifungals could be applied. Both patients were treated with different antifungal drugs, but only the second one survived due to therapy with fosmanogepix®. The current treatment is still based on a combination of conventional antifungal drugs, although in much cases this strategy is not sufficient. The introduction of new promising antifungal agents such as fosmanogepix® and olorofim® may open new perspectives in the treatment of invasive infections caused by L. prolificans, as in our patient.

New Insights Into The Melanin Structure Of Lomentospora prolificans

Lomentospora prolificans is a filamentous fungus with a global distribution, manifesting particularly higher prevalence in human-impacted environments. This organism is associated with a wide spectrum of human infections, especially in immunosuppressed individuals, for whom it causes severe and debilitating illnesses with high morbidity and mortality that are compounded by its pan-resistant profile with respect to antifungal drugs. Melanin is a ubiquitous pigment among fungi with a broad range of actions that include promoting fungal virulence. Although melanin is one of the most studied virulence factors in pathogenic fungi, relatively little is known about the chemistry of this pigment in L. prolificans. In the current study we characterized L. prolificans-associated melanin using chemical, biological, biophysical and structural techniques, also assessing the impact of inhibitors of distinct melanization pathways. Our results reveal that this pathogenic fungus makes multiple types of melanin pigments and suggests the possibility of a new type of melanin, which is synthesized together with a mixture of DHN-, DOPA- and pyomelanin types. These insights enhance our understanding of L. prolificans' virulence mechanisms, paving the way for potential therapeutic interventions.

Do morphogenetic switching and intraspecies variation enhance virulence of Candida auris?

Intraspecies variations that affect pathogenicity and antifungal resistance traits pose a serious obstacle to efficient therapy of Candida auris infections. Recent reports indicate that mutations determine drug susceptibility and virulence. However, mutations alone cannot fully explain a bewildering variety of phenotypes in clinical isolates from known C. auris clades, suggesting an unprecedented complexity underlying virulence traits and antifungal resistance. Hence, we wish to discuss how phenotypic plasticity promotes morphogenetic switching and how that contributes to intraspecies variations in the human fungal pathogen C. auris. Further, we will also discuss how intraspecies variations and morphogenetic events can impact the progress in molecular mycology research that aims to find better treatments for C. auris infections. Finally, we will present our opinion as to the most relevant questions to be addressed when trying to better understand the pathophysiology of C. auris.

Practical Guidance for Clinical Microbiology Laboratories: Updated guidance for processing respiratory tract samples from people with cystic fibrosis

SUMMARYThis guidance presents recommendations for clinical microbiology laboratories for processing respiratory samples from people with cystic fibrosis (pwCF). Appropriate processing of respiratory samples is crucial to detect bacterial and fungal pathogens, guide treatment, monitor the epidemiology of cystic fibrosis (CF) pathogens, and assess therapeutic interventions. Thanks to CF transmembrane conductance regulator modulator therapy, the health of pwCF has improved, but as a result, fewer pwCF spontaneously expectorate sputum. Thus, the collection of sputum samples has decreased, while the collection of other types of respiratory samples such as oropharyngeal and bronchoalveolar lavage samples has increased. To optimize the detection of microorganisms, including Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae, and Burkholderia cepacia complex; other less common non-lactose fermenting Gram-negative bacilli, e.g., Stenotrophomonas maltophilia, Inquilinus, Achromobacter, Ralstonia, and Pandoraea species; and yeasts and filamentous fungi, non-selective and selective culture media are recommended for all types of respiratory samples, including samples obtained from pwCF after lung transplantation. There are no consensus recommendations for laboratory practices to detect, characterize, and report small colony variants (SCVs) of S. aureus, although studies are ongoing to address the potential clinical impact of SCVs. Accurate identification of less common Gram-negative bacilli, e.g., S. maltophilia, Inquilinus, Achromobacter, Ralstonia, and Pandoraea species, as well as yeasts and filamentous fungi, is recommended to understand their epidemiology and clinical importance in pwCF. However, conventional biochemical tests and automated platforms may not accurately identify CF pathogens. MALDI-TOF MS provides excellent genus-level identification, but databases may lack representation of CF pathogens to the species-level. Thus, DNA sequence analysis should be routinely available to laboratories for selected clinical circumstances. Antimicrobial susceptibility testing (AST) is not recommended for every routine surveillance culture obtained from pwCF, although selective AST may be helpful, e.g., for unusual pathogens or exacerbations unresponsive to initial therapy. While this guidance reflects current care paradigms for pwCF, recommendations will continue to evolve as CF research expands the evidence base for laboratory practices.

Disseminated Lomentospora prolificans infection that could have been predicted: A case report

Lomentospora prolificans is a rare, filamentous fungus, that causes a disseminated infection in immunocompromised individuals. Disseminated infections caused by the fungus are difficult to diagnose early. It is resistant to multiple antifungal agents and has a high mortality rate. We encountered a case in which the involvement of this fungus was indicated by a history of antifungal prophylaxis and an elevated serum 1,3-beta-D-glucan (BDG) level. A 76-year-old female with myelodysplastic syndrome that developed into overt leukemia was administered oral posaconazole as antifungal prophylaxis. She was admitted to the hospital to determine the cause of her fever, where no new abnormalities other than an elevated serum BDG level were observed. Unfortunately, the patient died due to acute respiratory failure on the same day of admission. The day after her death, L. prolificans was detected in a blood culture taken upon her admission. L. prolificans should be suspected based on the history of antifungal prophylaxis and an elevated serum BDG level, as these are risk factors for infection by this pathogen. Blood cultures are useful to provide a diagnosis. If treated early, before it is detected in culture, the mortality rate can be decreased.

Scedosporiosis and lomentosporiosis: modern perspectives on these difficult-to-treat rare mold infections

SUMMARYAlthough Scedosporium species and Lomentospora prolificans are uncommon causes of invasive fungal diseases (IFDs), these infections are associated with high mortality and are costly to treat with a limited armamentarium of antifungal drugs. In light of recent advances, including in the area of new antifungals, the present review provides a timely and updated overview of these IFDs, with a focus on the taxonomy, clinical epidemiology, pathogenesis and host immune response, disease manifestations, diagnosis, antifungal susceptibility, and treatment. An expansion of hosts at risk for these difficult-to-treat infections has emerged over the last two decades given the increased use of, and broader population treated with, immunomodulatory and targeted molecular agents as well as wider adoption of antifungal prophylaxis. Clinical presentations differ not only between genera but also across the different Scedosporium species. L. prolificans is intrinsically resistant to most currently available antifungal agents, and the prognosis of immunocompromised patients with lomentosporiosis is poor. Development of, and improved access to, diagnostic modalities for early detection of these rare mold infections is paramount for timely targeted antifungal therapy and surgery if indicated. New antifungal agents (e.g., olorofim, fosmanogepix) with novel mechanisms of action and less cross-resistance to existing classes, availability of formulations for oral administration, and fewer drug-drug interactions are now in late-stage clinical trials, and soon, could extend options to treat scedosporiosis/lomentosporiosis. Much work remains to increase our understanding of these infections, especially in the pediatric setting. Knowledge gaps for future research are highlighted in the review.

A case of Scedosporium prolificans pulmonary infection in a patient with acute myeloid leukemia

An elderly woman with a history of myelodysplastic syndrome complicated by cavitary pneumonia treated with antibiotics and antifungal therapy was admitted with severe sepsis and pulmonary opacities on imaging. Pulmonary infection with Scedosporium prolificans, was diagnosed on bronchopulmonary lavage (BAL). This common environmental fungus is known to cause rare but severe infection in immunocompromised hosts. The patient was diagnosed with progression to acute myeloid leukemia during the hospitalization for which chemotherapy was initiated. Despite broadening antifungal therapy, the patient developed multi-organ system failure and died.

Deciphering Unexpected Vascular Locations of Scedosporium spp. and Lomentospora prolificans Fungal Infections, France

Scedosporium spp. and Lomentospora prolificans are emerging non-Aspergillus filamentous fungi. The Scedosporiosis/lomentosporiosis Observational Study we previously conducted reported frequent fungal vascular involvement, including aortitis and peripheral arteritis. For this article, we reviewed 7 cases of Scedosporium spp. and L. prolificans arteritis from the Scedosporiosis/lomentosporiosis Observational Study and 13 cases from published literature. Underlying immunosuppression was reported in 70% (14/20) of case-patients, mainly those who had solid organ transplants (10/14). Osteoarticular localization of infection was observed in 50% (10/20) of cases; infections were frequently (7/10) contiguous with vascular infection sites. Scedosporium spp./Lomentospora prolificans infections were diagnosed in 9 of 20 patients ≈3 months after completing treatment for nonvascular scedosporiosis/lomentosporiosis. Aneurysms were found in 8/11 aortitis and 6/10 peripheral arteritis cases. Invasive fungal disease--related deaths were high (12/18 [67%]). The vascular tropism of Scedosporium spp. and L. prolificans indicates vascular imaging, such as computed tomography angiography, is needed to manage infections, especially for osteoarticular locations.

Myocarditis and brain abscess caused by disseminated Scedosporium boydii infection

Scedosporium spp. is a fungal species documented as the cause of infections involving the lungs, brain, and other organ systems in both immunocompetent and immunocompromised individuals. Many cases of this type of fungal infection occurring in immunocompetent patients are subsequent to traumatic injury or drowning events in or near waters containing the fungi. Infection commonly involves the lungs. Rarely, it has been shown to cause disease in the endocardium, but there is even less documentation of the fungi invading the myocardium and causing myocarditis. In this report, we present a case of disseminated Scedosporium boydii infection in a 52-year-old male patient without any known risk factors. He presented with acute onset chest pain and dyspnea accompanied by bilateral lower extremity edema. He was found to have new onset heart failure with reduced ejection fraction, and his hospital course was complicated by pneumonia, disseminated intravascular coagulation (DIC), and brain abscess formation. Multiple blood cultures failed to reveal the source of the infection. At autopsy, septated branching hyphae were identified invading both the myocardium and the cortical brain tissue. DNA sequencing revealed the fungal organisms to be Scedosporium boydii. This case reinforces the importance of autopsies in the clinical setting. It not only established the definitive diagnosis of an unexpected fungal infection, but it also helped to recognize new clinical and pathologic features of this particular fungal organism.

Disseminated Infection by Scedosporium/Lomentospora during Induction Therapy for Acute Myeloid Leukemia Complicated by Nontuberculous Mycobacteria

Scedosporium/Lomentospora infections are rare and are associated with a high mortality rate in immunocompromised patients. A 69-year-old man with nontuberculous mycobacteria (NTM) died during induction chemotherapy for acute myeloid leukemia because of multiple organ failure due to pneumonia. During an autopsy, Lomentospora prolificans was detected using a fungal gene analysis of the blood, lungs, spleen, kidneys, and intestines, and Scedosporium aurantiacum was detected in the lungs. NTM disease may predispose patients to Scedosporium/Lomentospora infections. Physicians should consider Scedosporium/Lomentospora spp. as an invasive fungal infection that occurs during myelosuppression, particularly when NTM is a complication.

Fusarium, Scedosporium and Other Rare Mold Invasive Infections: Over Twenty-Five-Year Experience of a European Tertiary-Care Center

Invasive mold infections (IMD) are an emerging concern due to the growing prevalence of patients at risk, encompassing but not limited to allogeneic hematopoietic stem cell transplant recipients, hematological malignancies patients, solid organ transplant recipients and intensive care unit patients. In contrast with invasive aspergillosis and mucormycosis, other hyalohyphomycoses and phaeohyphomycoses remain poorly known. We conducted a retrospective analysis of the clinical, biological, microbiological and evolutive features of 92 IMD having occurred in patients in our tertiary-care center over more than 25 years. A quarter of these infections were due to multiple molds. Molds involved were Fusarium spp. (36.2% of IMD with a single agent, 43.5% of IMD with multiple agents), followed by Scedosporium spp. (respectively 14.5% and 26.1%) and Alternaria spp. (respectively 13.0% and 8.7%). Mortality at day 84 was higher for Fusarium spp., Scedosporium spp. or multiple pathogens IMD compared with Alternaria or other pathogens (51.7% vs. 17.6%, p < 0.05). Mortality at day 84 was also influenced by host factor: higher among hematology and alloHSCT patients than in other patients (30.6% vs. 20.9% at day 42 and 50.0% vs. 27.9% at day 84, p = 0.041). Better awareness, understanding and treatments are awaited to improve patient prognosis.

A case of Lomentospora prolificans endophthalmitis treated with the novel antifungal agent Olorofim

PURPOSE

To report a case of endogenous Lomentospora prolificans endophthalmitis treated with the novel antifungal agent Olorofim.

CASE REPORT

A 57-year-old man developed disseminated Lomentospora prolificans with right endophthalmitis on the background of immunosuppression following lung transplantation for interstitial lung disease. He was treated with early vitrectomy, intravitreal voriconazole, and systemic Olorofim, voriconazole and terbinafine. His symptoms improved and remained stable in the right eye. Eight weeks later the patient represented with Lomentopora prolificans endophthalmitis in the left eye when systemic voriconazole and terbinafine treatment were withdrawn. Despite aggressive treatment he ultimately succumbed due to vascular complications of extensive disseminated disease.

CONCLUSION

We report a rare case of disseminated Lomentosporosis with panophthalmitis in an immunocompromised host with prolonged survival on systemic Olorofim, voriconazole and terbinafine in conjunction with pars plana vitrectomy and intravitreal voriconazole. Early suspicion of an opportunistic fungal infection is critical, as managing disseminated disease is often unsuccessful. Despite presumed inherent resistance, intravitreal and systemic voriconazole appeared to limit disease progression in the right eye. The potential synergistic effects of combined antifungal therapy with orotomides warrant further investigation.

A rare case of scedosporium apiospermum osteomyelitis in an immunocompetent patient

Scedosporium, a widespread filamentous fungus found in diverse environments, has experienced a rise in cases due to escalating malignancies and chronic immunosuppression. Clinical manifestations span mycetoma, airway involvement, and various infections, with osteomyelitis being a notable complication. We present a case of a 77-year-old female initially displaying cutaneous Scedosporium signs, which progressed to osteomyelitis. The patient, with a history of trauma, chronic low dose steroid use, and underlying conditions, presented with a foot injury caused by her dog. Despite initial management, worsening symptoms led to the identification of Scedosporium. A comprehensive approach involving debridement, antimicrobial therapy, and reduction of immunosuppression resulted in clinical improvement. The rarity of zoonotic transmission, diagnostic challenges, and antifungal efficacy are also discussed. The patient's positive trajectory emphasizes early diagnosis, targeted treatment, and vigilance in managing immunosuppression. An adaptable treatment protocol is proposed based on risk factors. Considering the rising opportunistic fungal infections and delayed culture results, initiating empirical antifungals based on clinical judgment and regional prevalence is vital for favorable outcomes.

Detection of Scedosporium spp.: Colonizer or pathogen? A retrospective analysis of clinical significance and management in a large tertiary center

Infections with Scedosporium spp. are emerging in the past two decades and are associated with a high mortality rate. Microbiological detection can be associated with either colonization or infection. Evolution from colonization into infection is difficult to predict and clinical management upon microbiological detection is complex. Microbiological samples from 2015 to 2021 were retrospectively analyzed in a single tertiary care center. Classification into colonization or infection was performed upon first microbiological detection. Clinical evolution was observed until July 2023. Further diagnostic procedures after initial detection were analyzed. Among 38 patients with microbiological detection of Scedosporium spp., 10 were diagnosed with an infection at the initial detection and two progressed from colonization to infection during the observation time. The main sites of infection were lung (5/12; 41.6%) followed by ocular sites (4/12; 33.3%). Imaging, bronchoscopy or biopsies upon detection were performed in a minority of patients. Overall mortality rate was similar in both groups initially classified as colonization or infection [30.7% and 33.3%, respectively (P = 1.0)]. In all patients where surgical debridement of site of infection was performed (5/12; 42%); no death was observed. Although death occurred more often in the group without eradication (3/4; 75%) compared with the group with successful eradication (1/8; 12.5%), statistical significance could not be reached (P = 0.053). As therapeutic management directly impacts patients' outcome, a multidisciplinary approach upon microbiological detection of Scedosporium spp. should be encouraged. Data from larger cohorts are warranted in order to analyze contributing factors favoring the evolution from colonization into infection.

Update on therapeutic approaches for invasive fungal infections in adults

Invasive fungal infections are increasingly encountered with the expansion of iatrogenic immunosuppression, including not only solid organ and hematopoietic stem cell transplant recipients but also patients with malignancies or autoimmune diseases receiving immunomodulatory therapies, such as Bruton Tyrosine Kinase (BTK) inhibitor. Their attributable mortality remains elevated, part of which is a contribution from globally emerging resistance in both molds and yeasts. Because antifungal susceptibility test results are often unavailable or delayed, empiric and tailored antifungal approaches including choice of agent(s) and use of combination therapy are heterogeneous and often based on clinician experience with knowledge of host's net state of immunosuppression, prior antifungal exposure, antifungal side effects and interaction profile, clinical severity of disease including site(s) of infection and local resistance data. In this review, we aim to summarize previous recommendations and most recent literature on treatment of invasive mold and yeast infections in adults to guide optimal evidence-based therapeutic approaches. We review the recent data that support use of available antifungal agents, including the different triazoles that have now been studied in comparison to previously preferred agents. We discuss management of complex infections with specific emerging fungi such as Scedosporium spp., Fusarium spp., Trichosporon asahii, and Candida auris. We briefly explore newer antifungal agents or formulations that are now being investigated to overcome therapeutic pitfalls, including but not limited to olorofim, rezafungin, fosmanogepix, and encochleated Amphotericin B. We discuss the role of surgical resection or debridement, duration of treatment, follow-up modalities, and need for secondary prophylaxis, all of which remain challenging, especially in patients chronically immunocompromised or awaiting more immunosuppressive therapies.

Scedosporium boydii finding in an immunocompromised patient and review of the literature

BACKGROUND

Scedosporiasis is an emerging mycosis that has gained importance in recent years due to its worldwide prevalence. It is caused by species of the Scedosporium apiospermum complex. These species can cause opportunistic infections in immunocompromised patients and, occasionally, in immunocompetent patients as well. The high intrinsic antifungal resistance make these infections difficult to manage.

AIMS

The objective of this study was to interpret the mycological findings in a transplant patient, together with the images obtained in the radiological studies, in order to provide an early and effective antifungal therapy.

METHODS

The mycological analysis of samples taken from a heart transplant patient with radiological images suggesting a fungal infection was performed. Computed tomography scan of the head and thorax showed space-occupying lesions in both the frontal lobe and cerebellum, and multiple pulmonary nodules. The nodules were punctured and the samples obtained were analyzed according to the procedures for mycological analysis. The identity of the isolates was confirmed by nucleotide sequencing. Eventually, the antifungal susceptibility was studied.

RESULTS

The fungal isolates obtained, whose identity was confirmed by sequencing, belonged to the species Scedosporium boydii. Injured tissues were surgically removed and a treatment with amphotericin B and voriconazole-minimum inhibitory concentration (MIC) 0.5μg/mL and ≥0.5μg/mL respectively - was administered.

CONCLUSIONS

Although the patient died due to complications of a Klebsiella pneumoniae sepsis refractory to treatment, the progression of the fungal disease, although slow, was favourable in the early phases of the treatment due to a correct diagnosis and the antifungal susceptibility test carried out. Clinical cases of this nature highlight the need to increase the epidemiological study of these microorganisms, as well as the proper treatment of the diseases caused, in order to achieve early diagnoses that reduce the morbidity and mortality of patients.

Scedosporium Sinusitis: A Rare Opportunistic Infection

Scedosporium sinusitis is an opportunistic fungal infection that is difficult to treat due to its inherent resistance to many antifungal agents. Infections may cause both localized or disseminated disease usually in skin and soft tissues. Immunocompetent persons are typically unaffected and disseminated disease occurs in immunocompromised hosts. Scedosporiumis a common hyaline mold causing sinopulmonary disease in those with hematologic malignancies and neutropenia. A 38-year-old Caucasian male with a medical history significant for HIV with intermittent treatment compliance, high-grade diffuse large B cell lymphoma (DLBCL) on chemotherapy, and hemophagocytic lymphohistiocytosis (HLH) presented with right-sided facial pain and fever. Maxillofacial computed tomography (CT) showed thickening and opacification of the sphenoid and maxillary sinuses concerning for fungal sinusitis. Endoscopic transsphenoidal debridement showed fungal growth of Scedosporium and the patient's blood cultures were ultimately negative. The patient underwent debridement of fungal sinusitis as well as right medial maxillectomy and ethmoidectomy. A three-month course of voriconazole was started and completed with weekly liver enzyme tests to monitor medication side effects. He has since been observed well as an outpatient with his oncologist after three months loss to follow-up and his infection has resolved.

Scedosporium species and Lomentospora prolificans fungaemia is uniformly fatal in patients with haematological malignancy

Scedosporium and Lomentospora species are environmental moulds that are virulent in immunocompromised hosts and rarely cause bloodstream infection (BSI). Patients with Scedosporium and Lomentospora species BSI were identified by the state public laboratory service in Queensland, Australia, over a 20-year period. Twenty-two incident episodes occurred among 21 residents; one patient had a second episode 321 days following the first. Of these, 18 were Lomentospora prolificans, three were Scedosporium apiospermum complex and one was a nonspeciated Scedosporium species. Seventeen (81%) patients died during their index admission, and all-cause mortality at 30, 90 and 365 days was 73%, 82% and 91% respectively. All 20 patients with haematological malignancy died within 365 days of follow-up with a median time to death of 9 days (interquartile range, 6-20 days) following diagnoses of BSI.

Microwave-Assisted Synthesis of Aminophosphonic Derivatives and Their Antifungal Evaluation against Lomentospora prolificans

Lomentospora prolificans is a pathogenic and multidrug-resistant fungus that can infect both immunocompetent and immunocompromised patients, with mortality rates up to 87%. The World Health Organization (WHO) included this fungal species in its first list of 19 priority fungal pathogens, which focused on fungal pathogens that can cause invasive acute and subacute systemic fungal infections. Therefore, there is a growing interest in finding new therapeutic alternatives. In this work, the synthesis of twelve α-aminophosphonates by the microwave-assisted Kabachnik-Fields reaction and twelve α-aminophosphonic acids by a monohydrolysis reaction is reported. All compounds were evaluated by the agar diffusion method as a preliminary screening in comparison with voriconazole, showing inhibition halos for compounds 7, 11, 13, 22 and 27. The five active compounds in the preliminary tests were evaluated against five strains of L. prolificans following protocol M38-A2 from CLSI. The results showed that these compounds exhibit antifungal activity in the concentration range of 900->900 μg/mL. Cytotoxicity against healthy COS-7 cells was also evaluated by the MTT assay, and it was shown that compound 22 was the least cytotoxic, with a viability of 67.91%, comparable to the viability exhibited by voriconazole (68.55%). Docking studies showed that the possible mechanism of action of the active compounds could be through the inhibition of the enzyme lanosterol-14-alpha-demethylase in an allosteric hydrophobic cavity.

Pulmonary scedosporiosis caused by Lomentospora prolificans in a patient who is immunocompetent: A rare case report

Infections with Scedosporium and Lomentospora species are usually found in patients who are immunodeficient, particularly in the transplant population. However, they are relatively rare in patients who are immunocompetent, which is especially useful in ruling out near-drowning and aspiration situations. Here, we report a case of a patient who is immunocompetent, with clinically suspected community-acquired pneumonia caused by Lomentospora prolificans detected by metagenomics next-generation sequencing (mNGS) and polymerase chain reaction from bronchoalveolar lavage fluid. This case highlights mNGS in the clinical diagnosis of pulmonary invasive fungal disease. mNGS is proposed as an important adjunctive diagnostic approach for rare pathogens.

Invasive bone and joint infections from the French Scedosporiosis/lomentosporiosis Observational Study (SOS) cohort: no mortality with long-term antifungal treatment and surgery

Little is known about localized osteoarticular Scedosporiosis (LOS). Most data come from case reports and small case series. Here we present an ancillary study of the nationwide French Scedosporiosis Observational Study (SOS), describing 15 consecutive cases of LOS diagnosed between January 2005 and March 2017. Adult patients diagnosed with LOS defined by osteoarticular involvement without distant foci reported in SOS were included. Fifteen LOS were analyzed. Seven patients had underlying disease. Fourteen patients had prior trauma as potential inoculation. Clinical presentation was arthritis (n = 8), osteitis (n = 5), and thoracic wall infection (n = 2). The most common clinical manifestation was pain (n = 9), followed by localized swelling (n = 7), cutaneous fistulization (n = 7), and fever (n = 5). The species involved were Scedosporium apiospermum (n = 8), S. boydii (n = 3), S. dehoogii (n = 1), and Lomentospora prolificans (n = 3). The species distribution was unremarkable except for S. boydii, which was associated with healthcare-related inoculations. Management was based on medical and surgical treatment for 13 patients. Fourteen patients received antifungal treatment for a median duration of 7 months. No patients died during follow-up. LOS exclusively occurred in the context of inoculation or systemic predisposing factors. It has a non-specific clinical presentation and is associated with an overall good clinical outcome, provided there is a prolonged course of antifungal therapy and adequate surgical management.

In Vitro Activity of the Novel Antifungal Olorofim against Scedosporium and Lomentospora prolificans

Scedosporium spp. and Lomentospora prolificans are an emerging group of fungi refractory to current antifungal treatments. These species largely affect immunocompromised individuals but can also be lung colonizers in cystic fibrosis patients. Although Scedosporium apiospermum is thought to be the predominant species, the group has been expanded to a species complex. The distribution of species within the S. apiospermum species complex and other closely related species in the United States is largely unknown. Here, we used β-tubulin and ITS sequences to identify 37 Scedosporium isolates to the species level. These Scedosporium isolates as well as 13 L. prolificans isolates were tested against a panel of nine antifungal drugs, including the first in novel class orotimide, olorofim. IMPORTANCE Scedosporium and Lomentospora infections are notoriously hard to treat as these organisms can be resistant to numerous antifungals. The manuscript contributes to our knowledge of the activity of the new antifungal agent olorofim and comparator agents against Lomentospora and against Scedosporium isolates that have been molecularly identified to the species level. The efficacy of olorofim against all species of Scedosporium and Lomentospora was confirmed.

Pandemic Response Box® library as a source of antifungal drugs against Scedosporium and Lomentospora species

Scedosporium and Lomentospora species are opportunistic filamentous fungi that cause localized and disseminated infections in immunocompetent and immunocompromised patients. These species are considered resistant fungi due to their low susceptibility to most current antifungal agents used in healthcare settings. The search for new compounds that could work as promising candidate antifungal drugs is an increasing field of interest. In this context, in the present study we screened the Pandemic Response Box® library (Medicines for Malaria Venture [MMV], Switzerland) to identify compounds with antifungal activity against Scedosporium and Lomentospora species. An initial screening of the drugs from this collection at 5 μM was performed using a clinical Scedosporium aurantiacum isolate according to the EUCAST protocol. Compounds with activity against this fungus were also tested against four other species (S. boydii¸ S. dehoogii, S. apiospermum and L. prolificans) at concentrations ranging from 0.078 to 10 μM. Seven compounds inhibited more than 80% of S. aurantiacum growth, three of them (alexidine, amorolfine and olorofim) were selected due to their differences in mechanism of action, especially when compared to drugs from the azole class. These compounds were more active against biofilm formation than against preformed biofilm in Scedosporium and Lomentospora species, except alexidine, which was able to decrease preformed biofilm about 50%. Analysis of the potential synergism of these compounds with voriconazole and caspofungin was performed by the checkerboard method for S. aurantiacum. The analysis by Bliss methodology revealed synergistic effects among selected drugs with caspofungin. When these drugs were combined with voriconazole, only alexidine and amorolfine showed a synergistic effect, whereas olorofim showed an antagonistic effect. Scanning electron microscopy revealed that alexidine induces morphology alterations in S. aurantiacum biofilm grown on a catheter surface. Reactive oxygen species production, mitochondrial activity and surface components were analyzed by fluorescent probes when S. aurantiacum was treated with selected drugs and revealed that some cell parameters are altered by these compounds. In conclusion, alexidine, amorolfine and olorofim were identified as promising compounds to be studied against scedosporiosis and lomentosporiosis.

Lomentospora prolificans Disseminated Infections: A Systematic Review of Reported Cases

BACKGROUND

Lomentospora prolificans, a rare, highly virulent filamentous fungus with high rates of intrinsic resistance to antifungals, has been associated with different types of infections in immunocompromised as well as immunocompetent individuals.

OBJECTIVE

To systematically address all relevant evidence regarding L. prolificans disseminated infections in the literature.

METHODS

We searched Medline via PubMed and Scopus databases through July 2022. We performed a qualitative synthesis of published articles reporting disseminated infections from L. prolificans in humans.

RESULTS

A total of 87 studies describing 142 cases were included in our systematic review. The pathogen was most frequently reported in disseminated infections in Spain (n = 47), Australia (n = 33), the USA (n = 21), and Germany (n = 10). Among 142 reported cases, 48.5% were males. Underlying conditions identified for the majority of patients included malignancy (72.5%), hemopoietic stem cell transplantation (23.2%), solid organ transplantation (16%), and AIDS (2%). Lungs, central nervous system, skin, eyes, heart and bones/joints were the most commonly affected organs. Neutropenia was recorded in 52% of patients. The mortality rate was as high as 87.3%.

CONCLUSIONS

To the best of our knowledge, this is the first systematic review conducted on disseminated infections due to this rare microorganism. Physicians should be aware that L. prolificans can cause a diversity of infections with high mortality and primarily affects immunocompromised and neutropenic patients.

Extracellularly Released Molecules by the Multidrug-Resistant Fungal Pathogens Belonging to the Scedosporium Genus: An Overview Focused on Their Ecological Significance and Pathogenic Relevance

The multidrug-resistant species belonging to the Scedosporium genus are well recognized as saprophytic filamentous fungi found mainly in human impacted areas and that emerged as human pathogens in both immunocompetent and immunocompromised individuals. It is well recognized that some fungi are ubiquitous organisms that produce an enormous amount of extracellular molecules, including enzymes and secondary metabolites, as part of their basic physiology in order to satisfy their several biological processes. In this context, the molecules secreted by Scedosporium species are key weapons for successful colonization, nutrition and maintenance in both host and environmental sites. These biologically active released molecules have central relevance on fungal survival when colonizing ecological places contaminated with hydrocarbons, as well as during human infection, particularly contributing to the invasion/evasion of host cells and tissues, besides escaping from the cellular and humoral host immune responses. Based on these relevant premises, the present review compiled the published data reporting the main secreted molecules by Scedosporium species, which operate important physiopathological events associated with pathogenesis, diagnosis, antimicrobial activity and bioremediation of polluted environments.

Scedosporium apiospermum and Lichtheimia corymbifera Co-Infection Due to Inhalation of Biogas in Immunocompetent Patients: A Case Series

This is the first report describing co-infection of Scedosporium apiospermum and Lichtheimia corymbifera caused by biogas inhalation in two people without underlying medical conditions. Two patients fell into the same pig manure pit at the same time while rescuing another patient (this person died in a few hours) and inhaled biogas. Both patients were diagnosed with pulmonary fungal disease and developed acute liver failure around Day 52. Their results were negative for the 1,3-β-d-glucan test and weakly positive for the galactomannan test. They were treated with amphotericin B and/or posaconazole without surgery. The patient in case 2 required amphotericin B deoxycholate aerosol inhalation to complete the treatment. Both patients recovered completely. For patients with mucormycosis confined to the lungs who cannot tolerate intravenous drip amphotericin B, increasing the dose of nebulised administration maybe a salvage regimen.

Lomentospora prolificans: An Emerging Opportunistic Fungal Pathogen

Lomentospora prolificans is an emerging opportunistic pathogen that primarily affects immunocompromised individuals leading to disseminated disease with high mortality rates while also causing infections in healthy populations. Successful recovery from infection is difficult due to high rates of intrinsic resistance to antifungals. Rapid and readily available diagnostic methods, aggressive surgical debridement wherever appropriate, and effective and timely antifungal treatment are the pillars for successful management. Future research will need to clarify the environmental niche of the fungus, further investigate the pathophysiology of infection and define species-specific therapeutic targets.

Clinical utility of antifungal susceptibility testing

Invasive fungal diseases cause significant morbidity and mortality, in particular affecting immunocompromised patients. Resistant organisms are of increasing importance, yet there are many notable differences in the ability to both perform and interpret antifungal susceptibility testing compared with bacteria. In this review, we will highlight the strengths and limitations of resistance data of pathogenic yeasts and moulds that may be used to guide treatment and predict clinical outcomes.

Consensus guidelines for the diagnosis and management of invasive fungal disease due to moulds other than Aspergillus in the haematology/oncology setting, 2021

Invasive fungal disease (IFD) due to moulds other than Aspergillus is a significant cause of mortality in patients with malignancies or post haemopoietic stem cell transplantation. The current guidelines focus on the diagnosis and management of the common non-Aspergillus moulds (NAM), such as Mucorales, Scedosporium species (spp.), Lomentospora prolificans and Fusarium spp. Rare but emerging NAM including Paecilomyces variotii, Purpureocillium lilacinum and Scopulariopsis spp. are also reviewed. Culture and histological examination of tissue biopsy specimens remain the mainstay of diagnosis, but molecular methods are increasingly being used. As NAM frequently disseminate, blood cultures and skin examination with biopsy of any suspicious lesions are critically important. Treatment requires a multidisciplinary approach with surgical debridement as a central component. Other management strategies include control of the underlying disease/predisposing factors, augmentation of the host response and the reduction of immunosuppression. Carefully selected antifungal therapy, guided by susceptibility testing, is critical to cure. We also outline novel antifungal agents still in clinical trial which offer substantial potential for improved outcomes in the future. Paediatric recommendations follow those of adults. Ongoing epidemiological research, improvement in diagnostics and the development of new antifungal agents will continue to improve the poor outcomes that have been traditionally associated with IFD due to NAM.

Disseminated Lomentospora prolificans infection presenting with arterial exsanguination

Lomentospora prolificans is an opportunistic fungal pathogen found especially in Australia, Spain, Portugal, California, and the southern United States. Although it causes a wide spectrum of infections, disseminated L. prolificans infection remains very rare. The diagnosis and medical management are challenging. No clear guidelines are available for management. The treatment options are limited and mortality is high, especially for immunocompromised patients. In the present case report, we have highlighted the rare vascular effect of disseminated L. prolificans infection. We have reported the case of a 48-year-old immunocompromised man who had presented with a right groin mass. After extensive workup, the patient was found to have disseminated L. prolificans infection causing a superficial femoral artery pseudoaneurysm. A multidisciplinary team was involved to provide medical and surgical care. However, the patient died after treatment failure and withdrawal of support.

Scedosporium and Lomentospora Infections Are Infrequent, Difficult to Diagnose by Histology, and Highly Virulent

OBJECTIVE

To further characterize the histomorphology and clinicopathologic features of colonization and invasive disease by Scedosporium and Lomentospora.

METHODS

We conducted a 20-year retrospective study. Patients with at least 1 histopathology specimen and concurrent culture were included. Clinical features, histopathology, microbiology, and outcomes were analyzed.

RESULTS

Eighteen patients were identified, and all were immunocompromised. Eight patients had colonization, while 10 had invasive disease (pneumonia [n = 3], skin and soft-tissue infections [n = 3], disseminated disease [n = 4]). Scedosporium apiospermum was identified in 15 patients, Lomentospora prolificans in 2 patients, and Scedosporium ellipsoideum in 1 patient. Fungal elements were identified histologically in 11 patients. Granulomatous, suppurative, and necrotizing inflammation with irregular branching hyphae and characteristic microconidia were observed in 9 cases; conidiogenous cells were identified in 4 cases. Seven patients died of invasive disease despite therapy, and 3 recovered after treatment. No deaths were observed in patients with colonization.

CONCLUSIONS

Scedosporium and Lomentospora are rare, virulent opportunistic fungal pathogens. Fungal morphology may overlap with other hyaline molds, but identification of obovoid conidia should allow a diagnosis of non-Aspergillus hyalohyphomycosis and consideration of Scedosporium and Lomentospora. Histopathologic correlation with culture and polymerase chain reaction is critical for diagnosis and treatment.

Identification of Promising Antifungal Drugs against Scedosporium and Lomentospora Species after Screening of Pathogen Box Library

Fungal infections have been increasing during the last decades. Scedosporium and Lomentospora species are filamentous fungi most associated to those infections, especially in immunocompromised patients. Considering the limited options of treatment and the emergence of resistant isolates, an increasing concern motivates the development of new therapeutic alternatives. In this context, the present study screened the Pathogen Box library to identify compounds with antifungal activity against Scedosporium and Lomentospora. Using antifungal susceptibility tests, biofilm analysis, scanning electron microscopy (SEM), and synergism assay, auranofin and iodoquinol were found to present promising repurposing applications. Both compounds were active against different Scedosporium and Lomentospora, including planktonic cells and biofilm. SEM revealed morphological alterations and synergism analysis showed that both drugs present positive interactions with voriconazole, fluconazole, and caspofungin. These data suggest that auranofin and iodoquinol are promising compounds to be studied as repurposing approaches against scedosporiosis and lomentosporiosis.

EQUAL Score Scedosporiosis/Lomentosporiosis 2021: a European Confederation of Medical Mycology (ECMM) tool to quantify guideline adherence

Background

Invasive scedosporiosis and lomentosporiosis are life-threatening fungal infections in immunocompromised patients with complex diagnostic and treatment patterns.

Objectives

To develop a scoring tool to facilitate and quantify adherence to current guideline recommendations for diagnosis, treatment and follow-up of invasive scedosporiosis and lomentosporiosis.

Methods

Experts from European Confederation of Medical Mycology (ECMM) excellence centres reviewed current guidelines for scedosporiosis and lomentosporiosis. Recommendations for diagnosis, treatment and follow-up were summarized, assembled and weighted according to their strength of recommendation and level of evidence (strongly recommended = 3 points; moderately recommended = 2 points; marginally recommended = 1 point; recommended against = 0 points). Additional items considered of high importance for clinical management were also weighted.

Results

A total of 170 recommendations were identified. A 21-item tool was developed and embedded into the EQUAL score card. Nine items for diagnosis with 18 achievable points were assembled. For treatment, three general recommendation items with a maximal score of 9 were identified, while for specific antifungal treatment the two fungal pathogens were separated. Three and four items were established for scedosporiosis and lomentosporiosis, respectively, with a maximum achievable score of 3 due to the separation of different treatment options with the maximum point value of 3 for voriconazole-based treatment. Follow-up comprised two items (4 points maximum). Key recommendations for clinical outcome were weighted accordingly.

Conclusions

We propose the EQUAL Score Scedosporiosis/Lomentosporiosis to quantify adherence to current guideline recommendations for management of these rare infections. The score remains to be validated in real-life patient cohorts and correlated with patient outcome.

Global guideline for the diagnosis and management of rare mould infections: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology and the American Society for Microbiology

With increasing numbers of patients needing intensive care or who are immunosuppressed, infections caused by moulds other than Aspergillus spp or Mucorales are increasing. Although antifungal prophylaxis has shown effectiveness in preventing many invasive fungal infections, selective pressure has caused an increase of breakthrough infections caused by Fusarium, Lomentospora, and Scedosporium species, as well as by dematiaceous moulds, Rasamsonia, Schizophyllum, Scopulariopsis, Paecilomyces, Penicillium, Talaromyces and Purpureocillium species. Guidance on the complex multidisciplinary management of infections caused by these pathogens has the potential to improve prognosis. Management routes depend on the availability of diagnostic and therapeutic options. The present recommendations are part of the One World-One Guideline initiative to incorporate regional differences in the epidemiology and management of rare mould infections. Experts from 24 countries contributed their knowledge and analysed published evidence on the diagnosis and treatment of rare mould infections. This consensus document intends to provide practical guidance in clinical decision making by engaging physicians and scientists involved in various aspects of clinical management. Moreover, we identify areas of uncertainty and constraints in optimising this management.

Fatal recurrent disseminated Lomentospora prolificans infection during autologous hematopoietic stem cell transplantation: A case report and review, and discussion on the importance of prolonged neutropenia

Infections with Scedosporium and Lomentospora species, in particular Lomentospora (previously Scedosporium) prolificans, are nearly universally fatal and rapidly-progressive in the transplant population. We report a case of a patient with diffuse large B-cell lymphoma undergoing myelosuppressive chemotherapy who developed disseminated L. prolificans infection which afterward persisted in his knee joint. The infection was treated with early empiric triple antifungal therapy tailored to synergy studies, growth factors to quickly resolve neutropenia, and aggressive debridement (where possible) of infection sites, including amputation. He achieved an 11-month remission until undergoing autologous hematopoietic stem cell transplantation with deep myelosuppression, wherein recrudescent L. prolificans infection occurred, causing death. We highlight the importance of early treatment, synergy studies, and especially recovery of neutropenia in treating this devastating condition.

[Invasive fungal infection over the last 30 years]

Clinical mycology is in continuous development. The appearance of new clinical guidelines has made it possible to improve the approach to opportunistic fungal infections, especially in immunosuppressed patients (oncohematological and/or transplant recipients). At the same time, the development of new diagnostic tools and new antifungals with a greater spectrum of action and fewer side effects have led to faster diagnoses and treatments that are more effective. Along with these advances, there has been a change in the epidemiology of invasive fungal infection (IFI), with the appearance of new patients (e.g., COPD, liver cirrhosis, post-influenza) and new microorganisms (Candida auris, Lomentospora prolificans, mucorales), and resistant fungi (isolates of Aspergillus resistant to azoles) which the clinician must take into account when choosing the treatment of a patient with an IFI. In this paper we will briefly review the advances in recent decades and the emerging problems.

Dual fungal infection with Lomentospora prolificans and Aspergillus fumigatus: A pathogenetic diagnosis elucidated after two decades by sequential examinations

A 44-year-old male Japanese was admitted for further post-remission treatments for acute myeloid leukemia. He developed a right orbital abscess. An isolate of Lomentospora prolificans was obtained from the lesion, and orbital biopsy also revealed the presence of Aspergillus fumigatus. This fatal case involved a concurrent dual fungal infection.

Disseminated lomentosporiosis in a heart transplant recipient: Case report and review of the literature

BACKGROUND

Lomentospora prolificans (formerly S prolificans) is a saprophyte fungi that causes opportunistic infections in solid organ transplant (SOT) recipients. Resulting disseminated infections are difficult to treat and have a high mortality. Indications for antifungal prophylaxis after heart transplantation (HT) include CMV disease, reoperation, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), and high environmental exposure to Aspergillus spores. However, the risk of breakthrough infections, such as Lomentosporiosis, remains a cause of concern.

METHODS

We report the clinical findings, microbiology, treatment and outcome of a disseminated Lomentosporiosis in a heart transplant recipient with ECMO and antifungal prophylaxis.

RESULTS

A 25-year-old male with complex grown-up congenital heart disease (GUCHD) was admitted for HT. He presented severe post-surgical complications including acute kidney injury and right heart and respiratory failure requiring venoarterial-ECMO, continuous renal replacement therapy (CCRT) and later on (+14) a ventricular assist device (VAD). Ganciclovir, cotrimoxazole, and antifungal prophylaxis with anidulafungin at standard doses had been started on day + 3 post HT. The patient presented seizures (+4), pancytopenia with mild neutropenia (days + 6 to + 11), influenza B (+7), and bacteremic Pseudomonas aeruginosa ventilator associated pneumonia (VAP) (+10). On days + 14 to + 16 Lomentospora prolificans was recovered from blood cultures, broncho aspirate, catheter tip, and skin biopsy. Despite treatment with L-AMB, voriconazole and terbinafine the patients died on day 17 after HT. Necropsy revealed disseminated infection with fungal invasion in central nervous system, heart, lung, cutaneous, and subcutaneous tissue. Broth microdilution tests demonstrated resistance to all antifungals.

CONCLUSIONS

Lomentosporiosis is a rare complication that may emerge as a breakthrough invasive fungal infection in heart transplant recipients on ECMO despite antifungal prophylaxis.