Emerging fungal pathogens in immunocompromised patients: classification, diagnosis, and management

Alternaria arborescens and A. italica Causing Leaf Blotch on Celtis julianae in China

Celtis julianae Schneid. is widely planted as a versatile tree species with ecological and economic significance. In September 2022, a leaf blotch disease of C. julianae was observed in Nanjing, Jiangsu, China, with an infection incidence of 63%. The disease led to severe early defoliation, significantly affecting the ornamental and ecological value of the host tree. The accurate identification of pathogens is imperative to conducting further research and advancing disease control. Koch's postulates confirmed that the fungal isolates (B1-B9) were pathogenic to C. julianae. The morphology of the characteristics of the pathogen matched those of Alternaria spp. The internal transcribed spacer region (ITS), large subunit (LSU) and small subunit (SSU) regions of rRNA, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), Alternaria major allergen gene (Alt a 1), RNA polymerase second largest subunit (RPB2), and portions of translation elongation factor 1-alpha (TEF1-α) genes were sequenced. Based on multi-locus phylogenetic analyses and morphology, the pathogenic fungi were identified as Alternaria arborescens and A. italica. The findings provided useful information for disease management and enhanced the understanding of Alternaria species diversity in China. This is the first report of A. arborescens and A. italica causing leaf blotch of C. julianae in China and worldwide.

Curvularia lung infection mimics malignancy

Curvularia rarely causes human infections despite its ubiquity in the environment. It is most associated with allergic diseases such as chronic sinusitis and allergic bronchopulmonary mycosis; however, causing a lung mass is rarely reported in the literature. We describe an interesting case of a 57-year-old man with a history of asthma and localized prostate cancer diagnosed with a Curvularia-caused lung mass that responded quickly to itraconazole.

Prospective Study on Prophylactic Micafungin Sodium against Invasive Fungal Disease during Neutropenia in Pediatric & Adolescent Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation

Background: Invasive fungal diseases (IFDs) increase the mortality rate of patients with neutropenia who receive chemotherapy or have previously undergone hematopoietic stem cell transplantation (HSCT). Micafungin is a broad-spectrum echinocandin with minimal toxicity and low drug interactions. We therefore investigated the efficacy and safety of prophylactic micafungin in pediatric and adolescent patients who underwent autologous HSCT. Methods: This was a phase II, prospective, single-center, open-label, and single-arm study. From November 2011 to February 2017, 125 patients were screened from Seoul National University Children’s Hospital, Korea, and 112 were enrolled. Micafungin was administered intravenously at a dose of 1 mg/kg/day (maximum 50 mg/day) from day 8 of autologous HSCT until neutrophil engraftment. Treatment success was defined as the absence of proven, probable, or possible IFD up to 4 weeks after therapy. Results: The study protocol was achieved without premature interruption in 110 patients (98.2%). The reasons interrupting micafungin treatment included early death (n = 1) and patient refusal (n = 1). Treatment success was achieved in 109 patients (99.1%). Only one patient was diagnosed with probable IFD. No patients were diagnosed with possible or proven IFD. In the full analysis set, 21 patients (18.8%) experienced 22 adverse events (AEs); however, all AEs were classified as “unlikely” related to micafungin. No patient experienced grade IV AEs nor discontinued treatment, and none of the deaths were related to micafungin. Conclusions: Our study demonstrated that micafungin is a safe and effective option for antifungal prophylaxis in pediatric patients who underwent autologous HSCT, with promising efficacy without significant AEs.

Crowdsourced analysis of fungal growth and branching on microfluidic platforms

Fungal hyphal growth and branching are essential traits that allow fungi to spread and proliferate in many environments. This sustained growth is essential for a myriad of applications in health, agriculture, and industry. However, comparisons between different fungi are difficult in the absence of standardized metrics. Here, we used a microfluidic device featuring four different maze patterns to compare the growth velocity and branching frequency of fourteen filamentous fungi. These measurements result from the collective work of several labs in the form of a competition named the "Fungus Olympics." The competing fungi included five ascomycete species (ten strains total), two basidiomycete species, and two zygomycete species. We found that growth velocity within a straight channel varied from 1 to 4 μm/min. We also found that the time to complete mazes when fungal hyphae branched or turned at various angles did not correlate with linear growth velocity. We discovered that fungi in our study used one of two distinct strategies to traverse mazes: high-frequency branching in which all possible paths were explored, and low-frequency branching in which only one or two paths were explored. While the high-frequency branching helped fungi escape mazes with sharp turns faster, the low-frequency turning had a significant advantage in mazes with shallower turns. Future work will more systematically examine these trends.

Efficacy of Intravenous Itraconazole Versus Liposomal Amphotericin B as Empirical Antifungal Therapy in Hematological Malignancy with Persistent Fever and Neutropenia: Study Protocol for a Multicenter, Prospective, Randomized Non-inferiority Trial

Febrile neutropenia, a serious complication that can occur during the treatment of hematological malignancies, can sometimes be fatal owing to fungal infection. Prospective randomized trials indicated the utility of liposomal amphotericin B or caspofungin as an empirical antifungal therapy. Itraconazole, a broad-spectrum tri azole antifungal agent, is poorly absorbed in the intestines after oral absorption and makes it difficult to achieve a stable serum drug concentration. Therefore, an intravenous formulation might offer a potentially safer and more effective alternative. To compare the efficacy and safety of empirical antifungal therapy, patients will be randomly assigned to either the liposomal amphotericin B 3.0 mg/kg once daily group or the intravenous itraconazole 200 mg dose group with five stratification factors (disease risk, previous antifungal prophylaxis, age, sex, and institute). The primary endpoint will be overall favorable response, comprising five secondary endpoints: successful treatment of baseline infection by the end of the treatment; absence of breakthrough infection; no discontinuation of the antifungal treatment due to drug-related toxicity; fever resolution during neutropenia; and 7-day survival after termination of the antifungal treatment. The target sample size of 850 subjects is sufficient to prove the non inferiority of itraconazole compared with liposomal amphotericin B, with a non-inferiority margin of 10%, one sided significance level of 5%, and power of 90%.

Epidemiology, clinical aspects, outcomes and prognostic factors associated with Trichosporon fungaemia: results of an international multicentre study carried out at 23 medical centres

BACKGROUND

Trichosporon fungaemia (TF) episodes have increased in recent years and mortality rates remain high despite the advances in the management of sepsis. New concepts about its clinical course, treatment and microbiology need to be investigated for the better management of this infection.

OBJECTIVES

To describe the aetiology, natural history, clinical management and prognostic factors of TF.

METHODS

TF episodes documented between 2005 and 2018 in 23 South American centres were retrospectively investigated by using a standard clinical form. Molecular identification, antifungal susceptibility testing and biofilm production were also performed.

RESULTS

Eighty-eight TF episodes were studied. Patients had several underlying conditions, including haematological diseases (47.7%), post-operative status (34%), solid organ transplants (n = 7, 7.9%), among others. Seventy-three (82.9%) patients had a central venous catheter (CVC) at TF diagnosis. The 30 day mortality rate was 51.1%. Voriconazole-based therapy was given to 34 patients (38.6%), with a 30 day mortality rate of 38.2%. Multivariate predictors of 30 day mortality were age (OR 1.036), mechanical ventilation (OR 8.25) and persistent neutropenia (OR 9.299). CVC removal was associated with over 75% decreased risk of 30 day mortality (OR 0.241). Microbiological analyses revealed that 77.7% of the strains were identified as Trichosporon asahii, and voriconazole showed the strongest in vitro activity against Trichosporon spp. Most of the strains (63%) were considered medium or high biofilm producers.

CONCLUSIONS

Older age, mechanical ventilation and persistent neutropenia were associated with poor prognosis. CVC may play a role in the pathogenicity of TF and its removal was associated with a better prognosis.

Intravenous itraconazole compared with liposomal amphotericin B as empirical antifungal therapy in patients with neutropaenia and persistent fever

BACKGROUND

Fungal infections are a major complication of neutropaenia following chemotherapy. Their early diagnosis is difficult, and empirical antifungal treatment is widely used, and uses of less toxic drugs that reduce breakthrough infection are required.

OBJECTIVE

We conducted a multicentre, open-label, randomised, non-inferiority trial to compare the safety and efficacy of intravenous itraconazole (ivITCZ) and liposomal amphotericin B (LAmB) as empirical antifungal therapy in patients with haematological malignancies with neutropaenia and persistent fever.

METHODS

Patients with haematological malignancies who developed fever refractory to broad-spectrum antibacterial agents under neutropaenia conditions were enrolled. Patients were randomised for treatment with LAmB (3.0 mg/kg/d) or ivITCZ (induction: 400 mg/d, maintenance: 200 mg/d).

RESULTS

Observed overall favourable response rates of 17/52 (32.7%) and 18/50 (36.0%) in the LAmB and ivITCZ groups, with a model-based estimate of a 4% difference (90% CI, -12% to 20%), did not fulfil the statistical non-inferiority criterion. In the LAmB group, there were two cases of breakthrough infection and five cases of probable invasive fungal disease, whereas in the itraconazole group, neither breakthrough infection nor probable invasive fungal disease occurred. Patients in the ivITCZ group had significantly fewer grade 3-4 hypokalaemia-related events than LAmB group patients (P < .01). The overall incidence of adverse events tended to be lower in the ivITCZ group (P = .07).

CONCLUSION

ivITCZ showed similar efficacy and safety as LAmB as empirical antifungal therapy in haematological malignancy patients with febrile neutropaenia, although the small sample size and various limitations prevented demonstration of its non-inferiority.

Opportunistic phaeohyphomycoses in wild saffron cod Eleginus gracilis from waterways of Norton Sound and Toksook Bay, Alaska, USA

These case reports describe locally invasive black pigmented mycotic infections of the skin and gills of saffron cod Eleginus gracilis associated with 8 different opportunistic ascomycete fungi: Alternaria sp., Cladosporium herbarum, Chaetomium globosum, Cadophora luteo-olivacea, Penicillium sp., Phoma herbarum, Pseudophacidium ledi and Valsa sordida. These fungi were isolated on conventional media, identified according to morphological structures and confirmed by genetic sequencing. Several of these fungi are primary plant pathogens as well as opportunistic human pathogens in immunocompromised individuals. Several have also been described as causing opportunistic infections of fish. This case material represents the first report of C. luteo-olivacea, C. globosum, P. ledi and V. sordida as likely opportunistic fish pathogens in Alaskan watersheds of Norton Sound and south in Toksook Bay and possibly elsewhere.

Biological assessment of ozone therapy on experimental oral candidiasis in immunosuppressed rats

Immunosuppressive drugs can compromise local or general defense mechanisms and can lead to oral candidiasis. Ozone therapy has a wide range of applications in almost every field of dentistry. Its unique properties include immunostimulant, analgesic, antihypnotic, detoxicating, and antimicrobial actions. Sixty male healthy rats were immunosuppressed with dexamethasone in their drinking water one week before candida infection. The animals were divided into four equal groups. Rats of group 1 were kept without any manipulation and those of group II were given oral inoculums of C. albicans on the dorsal surface of the tongue. Group III rats were handled as group II and instead the rats were treated by daily mycostatin drops local applicator as a routine treatment. Meanwhile, group IV rats were handled as group II and instead the rats were received daily intraperitoneal injection of 1 cm³ of ozone oxygen gas mixture with concentration of ozone 70 μg/cm³. After two weeks, all rats were euthanized and tongue specimens were prepared for histological staining with Haematoxylin & Eosin and CD3 immunohistochemical staining. Histological examination revealed that treatment with ozone therapy lead to gradual decrease in lingual papillary atrophy and invasion of candida yeast. Immunohistochemical study showed significant decrease in CD3 counting. We can conclude that ozone acts as an excellent fungicidal agent also, ozone is capable of alerting the immune system.

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Immunosuppressive drugs can compromise local or general defense mechanisms and lead to oral candidiasis.

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Ozone therapy has a wide range of applications in many fields of dentistry.

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Ozone application has many beneficial effects on the oral tissues comprising remission of various mucosal alterations.

Solar photocatalytic disinfection of agricultural pathogenic fungi (Curvularia sp.) in real urban wastewater

The interest in developing alternative water disinfection methods that increase the access to irrigation water free of pathogens for agricultural purposes is increasing in the last decades. Advanced Oxidation Processes (AOPs) have been demonstrated to be very efficient for the abatement of several kind of pathogens in contaminated water. The purpose of the current study was to evaluate and compare the capability of several solar AOPs for the inactivation of resistant spores of agricultural fungi. Solar photoassisted H₂O₂, solar photo-Fenton at acid and near-neutral pH, and solar heterogeneous photocatalysis using TiO_2, with and without H₂O₂, have been studied for the inactivation of spores of Curvularia sp., a phytopathogenic fungi worldwide found in soils and crops. Different concentrations of reagents and catalysts were evaluated at bench scale (solar vessel reactors, 200mL) and at pilot plant scale (solar Compound Parabolic Collector-CPC reactor, 20L) under natural solar radiation using distilled water (DW) and real secondary effluents (SE) from a municipal wastewater treatment plant. Inactivation order of Curvularia sp. in distilled water was determined, i.e. TiO₂/H₂O₂/sunlight (100/50mgL^-1)>H₂O₂/sunlight (40mgL^-1)>TiO₂/sunlight (100mgL^-1)>photo-Fenton with 5/10mgL^-1 of Fe²⁺/H₂O₂ at pH3 and near-neutral pH. For the case of SE, at near neutral pH, the most efficient solar process was H₂O₂/Solar (60mgL^-1); nevertheless, the best Curvularia sp. inactivation rate was obtained with photo-Fenton (10/20mgL^-1 of Fe²⁺/H₂O₂) requiring a previous water adicification to pH3, within 300 and 210min of solar treatment, respectively. These results show the efficiency of solar AOPs as a feasible option for the inactivation of resistant pathogens in water for crops irrigation, even in the presence of organic matter (average Dissolved Organic Carbon (DOC): 24mgL^-1), and open a window for future wastewater reclamation and irrigation use.

Safety and efficacy of treatment with liposomal amphotericin B in elderly patients at least 65 years old with hematological diseases

The safety and efficacy of treatment with liposomal amphotericin B (L-AMB) in elderly patients has not been clarified, especially in Japanese patients. Therefore, we retrospectively analyzed 33 elderly patients with hematological diseases of at least 65 years old who received L-AMB between 2009 and 2012. Their clinical outcomes were compared to those of 21 patients who were younger than 65 years. L-AMB was administered for empirical therapy (n = 2) or target therapy for possible (n = 14) or probable/proven (n = 17) invasive fungal infection. There was no discontinuation of L-AMB due to adverse events. More than 2-fold increases from the baseline Cre, AST, and ALT values were observed in 21.2%, 39.4%, and 45.5% of the older group and 38.1%, 61.9%, and 52.4% of the younger group, respectively. The concurrent use of nephrotoxic antibiotics was the only risk factor for the development of a 2-fold increase in the serum Cre level. The duration of L-AMB was significantly longer in patients who developed grade III-IV hypokalemia. A partial or complete response was observed in 54.8% and 62.5% of the elderly and younger groups, respectively. In conclusion, L-AMB therapy appeared to be acceptably safe as empirical therapy or treatment for invasive fungal infection.

Meta-Analysis and Cost Comparison of Empirical versus Pre-Emptive Antifungal Strategies in Hematologic Malignancy Patients with High-Risk Febrile Neutropenia

BACKGROUND

Invasive fungal disease (IFD) causes significant morbidity and mortality in hematologic malignancy patients with high-risk febrile neutropenia (FN). These patients therefore often receive empirical antifungal therapy. Diagnostic test-guided pre-emptive antifungal therapy has been evaluated as an alternative treatment strategy in these patients.

METHODS

We conducted an electronic search for literature comparing empirical versus pre-emptive antifungal strategies in FN among adult hematologic malignancy patients. We systematically reviewed 9 studies, including randomized-controlled trials, cohort studies, and feasibility studies. Random and fixed-effect models were used to generate pooled relative risk estimates of IFD detection, IFD-related mortality, overall mortality, and rates and duration of antifungal therapy. Heterogeneity was measured via Cochran's Q test, I2 statistic, and between study τ2. Incorporating these parameters and direct costs of drugs and diagnostic testing, we constructed a comparative costing model for the two strategies. We conducted probabilistic sensitivity analysis on pooled estimates and one-way sensitivity analyses on other key parameters with uncertain estimates.

RESULTS

Nine published studies met inclusion criteria. Compared to empirical antifungal therapy, pre-emptive strategies were associated with significantly lower antifungal exposure (RR 0.48, 95% CI 0.27-0.85) and duration without an increase in IFD-related mortality (RR 0.82, 95% CI 0.36-1.87) or overall mortality (RR 0.95, 95% CI 0.46-1.99). The pre-emptive strategy cost $324 less (95% credible interval -$291.88 to $418.65 pre-emptive compared to empirical) than the empirical approach per FN episode. However, the cost difference was influenced by relatively small changes in costs of antifungal therapy and diagnostic testing.

CONCLUSIONS

Compared to empirical antifungal therapy, pre-emptive antifungal therapy in patients with high-risk FN may decrease antifungal use without increasing mortality. We demonstrate a state of economic equipoise between empirical and diagnostic-directed pre-emptive antifungal treatment strategies, influenced by small changes in cost of antifungal therapy and diagnostic testing, in the current literature. This work emphasizes the need for optimization of existing fungal diagnostic strategies, development of more efficient diagnostic strategies, and less toxic and more cost-effective antifungals.

Interaction of an opportunistic fungus Purpureocillium lilacinum with human macrophages and dendritic cells

INTRODUCTION

Purpureocillium lilacinum is emerging as a causal agent of hyalohyphomycosis that is refractory to antifungal drugs; however, the pathogenic mechanisms underlying P. lilacinum infection are not understood. In this study, we investigated the interaction of P. lilacinum conidia with human macrophages and dendritic cells in vitro.

METHODS

Spores of a P. lilacinum clinical isolate were obtained by chill-heat shock. Mononuclear cells were isolated from eight healthy individuals. Monocytes were separated by cold aggregation and differentiated into macrophages by incubation for 7 to 10 days at 37°C or into dendritic cells by the addition of the cytokines human granulocyte-macrophage colony stimulating factor and interleukin-4. Conidial suspension was added to the human cells at 1:1, 2:1, and 5:1 (conidia:cells) ratios for 1h, 6h, and 24h, and the infection was evaluated by Giemsa staining and light microscopy.

RESULTS

After 1h interaction, P. lilacinum conidia were internalized by human cells and after 6h contact, some conidia became inflated. After 24h interaction, the conidia produced germ tubes and hyphae, leading to the disruption of macrophage and dendritic cell membranes. The infection rate analyzed after 6h incubation of P. lilacinum conidia with cells at 2:1 and 1:1 ratios was 76.5% and 25.5%, respectively, for macrophages and 54.3% and 19.5%, respectively, for cultured dendritic cells.

CONCLUSIONS

P. lilacinum conidia are capable of infecting and destroying both macrophages and dendritic cells, clearly demonstrating the ability of this pathogenic fungus to invade human phagocytic cells.

Aspergillus, Penicillium and Talaromyces isolated from house dust samples collected around the world

As part of a worldwide survey of the indoor mycobiota, dust was collected from nine countries. Analyses of dust samples included the culture-dependent dilution-to-extinction method and the culture-independent 454-pyrosequencing. Of the 7 904 isolates, 2 717 isolates were identified as belonging to Aspergillus, Penicillium and Talaromyces. The aim of this study was to identify isolates to species level and describe the new species found. Secondly, we wanted to create a reliable reference sequence database to be used for next-generation sequencing projects. Isolates represented 59 Aspergillus species, including eight undescribed species, 49 Penicillium species of which seven were undescribed and 18 Talaromyces species including three described here as new. In total, 568 ITS barcodes were generated, and 391 β-tubulin and 507 calmodulin sequences, which serve as alternative identification markers.

[Nosocomial infection due to Trichosporon asahii in a critical burned patient]

BACKGROUND

Invasive fungal infection is an important cause of morbimortality in patients with severe burns. The advances in burn care therapy have considerably extended the survival of seriously burned patients, exposing them to infectious complications, notably fungal infections, with increased recognition of invasive infections caused by Candida species. However, some opportunistic fungi, like Trichosporon asahii, have emerged as important causes of nosocomial infection.

CASE REPORT

A case of nosocomial infection due to T. asahii in a severely ill burned patient successfully treated with voriconazole is presented. The management of invasive fungal infections in burned patients, from diagnosis to selection of the therapeutic protocol, is often a challenge. Early diagnosis and treatment are associated with a better prognosis. In this case report, current treatment options are discussed, and a review of previously published cases is presented.

CONCLUSIONS

Due to the difficulty in the diagnosis of invasive mycoses and their high associated mortality rates, it is advisable to keep a high degree of clinical suspicion of trichosporonosis in susceptible patients, including burned patients. The isolation of T. asahii in clinical specimens of this type of host must raise clinical alert, since it may precede an invasive infection.

Antiproliferative, antifungal, and antibacterial activities of endophytic alternaria species from cupressaceae

Recent research has shown the bioprospecting of endophytic fungi from Cupressaceae. Here, we further uncover that the healthy cypress plants such as Cupressus arizonica, Cupressus sempervirens var. cereiformis, and Thuja orientalis host highly bioactive endophytic Alternaria fungal species. Indeed, endophytic Alternaria alternata, Alternaria pellucida, and Alternaria tangelonis were recovered from healthy Cupressaceous trees. Biodiversity and bioactivity of recovered endophytic Alternaria species were a matter of biogeography and host identity. We further extracted such Alternaria's metabolites and highlighted their significant antiproliferative, growth inhibitory, and antibacterial activities against the model target fungus Pyricularia oryzae and the model pathogenic bacteria Bacillus sp., Erwinia amylovora, and Pseudomonas syringae. In vitro assays also indicated that endophytic Alternaria species significantly inhibited the growth of cypress fungal phytopathogens Diplodia seriata, Phaeobotryon cupressi, and Spencermartinsia viticola. In conclusion, since the recovered Alternaria species were originally reported as pathogenic and allergenic fungi, our findings suggest a possible ecological niche for them inside the foliar tissues of Cupressaceous trees. Moreover, in this study, the significant bioactivities of endophytic Alternaria species in association with Cupressaceae plant family are reported.

Our recommendations for avoiding exposure to fungi outside the hospital for patients with haematological cancers

Despite several chemotherapeutic and preventative advances, opportunistic fungal infections remain common unintended consequences of cancer treatment. Currently, cancer patients spend most of their time between treatments at home, where they can inadvertently come across potential hazards from environmental and food sources. Therefore, infection prevention measures are of the utmost importance for these patients. Although clinicians closely observe patients throughout their treatment courses in the hospital, the focus of clinical visits is predominantly on cancer care, and clinicians seldom provide recommendations for prevention of such infections. Herein, we provide practical recommendations for busy clinicians to help them educate patients regarding potential sources of fungal infections outside the hospital.

Delayed scleral buckle infection due to Alternaria species

OBJECTIVE

To report a case of scleral buckle infection by Alternaria fungus.

CASE REPORT

A 75-year-old male who underwent rhegmatogenous retinal detachment repair 11 years ago developed a scleral buckle infection during the course of serial injections of bevacizumab for the treatment of wet age-related macular degeneration. Removal of the scleral buckle was done and culture results revealed Alternaria species.

RESULTS

The infected scleral buckle was removed and the patient received oral voriconazole. The patient's best corrected visual acuity changed from 20/50 preoperatively to 20/150 six months after the procedure.

CONCLUSION

Alternaria species may be encountered as a cause of scleral buckle infection.

Overexpression of the trichodiene synthase gene tri5 increases trichodermin production and antimicrobial activity in Trichoderma brevicompactum

Trichoderma brevicompactum produces trichodermin, a simple trichothecene-type toxin that shares the first steps of the sesquiterpene biosynthetic pathway with other phytotoxic trichothecenes from Fusarium spp. Trichodiene synthase catalyses the conversion of farnesyl pyrophosphate to trichodiene and it is encoded by the tri5 gene that was cloned and analysed functionally by homologous overexpression in T. brevicompactum. tri5 expression was up-regulated in media with glucose, H(2)O(2) or glycerol. tri5 repression was observed in cultures supplemented with the antioxidants ferulic acid and tyrosol. Acetone extracts of tri5-overexpressing transformants displayed higher antifungal activity than those from the wild-type. Chromatographic and spectroscopic analyses revealed that tri5 overexpression led to an increased production of trichodermin and tyrosol. Agar diffusion assays with these two purified metabolites from the tri5-overexpressing transformant T. brevicompactum Tb41tri5 showed that only trichodermin had antifungal activity against Saccharomyces cerevisiae, Kluyveromyces marxianus, Candida albicans, Candida glabrata, Candida tropicalis and Aspergillus fumigatus, in most cases such activity being higher than that observed for amphotericin B and hygromycin. Our results point to the significant role of tri5 in the production of trichodermin and in the antifungal activity of T. brevicompactum.

Epidemiology and outcome of Rhodotorula infection in haematological patients

Rhodotorula spp. are emergent opportunistic pathogens, particularly in haematological patients. However, no systematic review of this infection has been undertaken in this high-risk patient group. The aim of this study was to review all reported cases of Rhodotorula infection to determine the epidemiology and outcome of this infection in this high-risk population. The 29 reported cases were fungaemias. The most common underlying haematological disorder was the presence of acute leukaemia (65.5%). Rhodotorula mucilaginosa was the species found more frequently (79.3%). Most cases (58.6%) had several risk factors (≥ 3) simultaneously. The most common predisposing factors were the presence of central venous catheter (CVC, 100%) and neutropenia (62.1%). A substantial number of patients (81.5%) received antifungal treatment with amphotericin B. The overall mortality was higher (13.8%) than that described in non-haematological patients (5.8% in solid-organ neoplasms and 9% in AIDS or other chronic diseases). Patients with acute leukaemia had a higher mortality rate (15.7%) than patients with non-Hodgkin's lymphoma (0%). Our data suggest that patients with acute leukaemia might be managed as high-risk patients and intensive measures might be taken. In addition, it appears that the subgroup of patients without acute leukaemia have a good outcome and might be managed as low-risk patients with a less intensive approach.

Clavispora lusitaniae and Chaetomium atrobrunneum as rare agents of cutaneous infection

We describe the first case of cutaneous infection caused by Chaetomium atrobrunneum and Clavispora lusitaniae in a one-and-a-half-year-old boy with acute and severe inflammation around his left eyelid. He presented to our outpatient center with a 6-day history and previously ineffective antibacterial therapy. Scanning electron microscopy (SEM) revealed hyphae and spores were on the surface of the crusty exudates and also penetrated into it, and the microbiology study further showed their characteristic cultural features. Fungal isolates were identified by the amplification and sequencing of the 26S RNA gene and of the ITS region, as C. lusitaniae and C. atrobrunneum. Up until now, most known clinical records of these rare species have shown them as agents of deep mycosis. Due to the emergency situation, medications were administered promptly and confirmed by subsequent fungal identification and successful therapeutic outcome. This article illustrates the importance of recognizing fungal infections, especially those caused by uncommon pathogens. Limitations in the routine identification procedures and therapeutic options of this emerging opportunistic agent are also discussed in this report.

Rhodotorula glutinis fungemia in a liver–kidney transplant patient

A 54-year-old man underwent simultaneous liver-kidney transplantation. During his prolonged hospitalization, he developed catheter-related fungemia with Rhodotorula glutinis and azole-resistant Candida glabrata. Management of the Rhodotorula fungemia was complicated by his renal insufficiency, hepatic insufficiency, and the concurrent fungemia with multi-azole resistant C. glabrata. He was treated with combination therapy with voriconazole and micafungin with subsequent clearance of the fungemia. Rhodotorula species are emerging as human pathogens with the increasing number of immunosuppressed patients in the last few decades. This is the first report of a R. glutinis fungemia in a solid organ transplant recipient.

Functional analyses of laccase genes from Fusarium oxysporum

Six laccase genes, lcc1, lcc2, lcc3, lcc4, lcc5, and lcc9, of the vascular wilt fungus Fusarium oxysporum were isolated and characterized. All genes have the characteristic conserved domains for copper binding of phenol oxidase enzymes. Targeted inactivation of lcc1, lcc3, and lcc5 resulted in a significant decrease of extracellular laccase activity. Reverse transcription-polymerase chain reaction showed that lcc1, lcc2, and lcc9 were constitutively expressed in culture, whereas lcc3 and lcc5 appeared down and up-regulated, respectively, by PacC. Oxidative stress conditions and phenolic compounds altered the growth rate of the Deltalcc3 mutant compared with the wild-type. lcc1, lcc3, and lcc9 were expressed in roots and stems during the infection process. However, inactivation of lcc1, lcc3, and lcc5 had no detectable effects on virulence on tomato plants.

Evaluation of Pyrosequencing technology for the identification of clinically relevant non-dematiaceous yeasts and related species

Pyrosequencing was used to identify 133 isolates of clinically relevant non-dematiaceous yeasts. These included 97 ATCC strains (42 type strains), seven UAMH strains, and 29 clinical isolates. Isolates belonged to the following genera: Candida (18 species), Trichosporon (10), Cryptococcus (7), Malassezia (3), Rhodotorula (2), Geotrichum (1), Blastoschizomyces (1), and Kodamaea (1). Amplicons of a hyper-variable ITS region were obtained and analyzed using Pyrosequencing technology. The data were evaluated by a BLAST search against the GenBank database and correlated with data obtained by conventional cycle sequencing of the ITS1-5.8S-ITS2 region. Cycle sequencing identified 78.9% of the isolates to the species level. Pyrosequencing technology identified 69.1%. In 90.1% of all of the strains tested, the identification results of both sequencing methods were identical. Most Candida isolates can be identified to the species level by Pyrosequencing. Trichosporon species and some Cryptococcus species cannot be differentiated at the species level. Pyrosequencing can be used for the reliable identification of most commonly isolated non-dematiaceous yeasts, with a reduction of cost per identification compared to conventional sequencing.

Fungal Infections

The incidence of invasive fungal infections has increased dramatically over the past two decades, mostly due to an increase in the number of immunocompromised patients.1–4 Patients who undergo chemotherapy for a variety of diseases, patients with organ transplants, and patients with the acquired immune deficiency syndrome have contributed most to the increase in fungal infections.5 The actual incidence of invasive fungal infections in transplant patients ranges from 15% to 25% in bone marrow transplant recipients to 5% to 42% in solid organ transplant recipients.6,7 The most frequently encountered are Aspergillus species, followed by Cryptococcus and Candida species. Fungal infections are also associated with a higher mortality than either bacterial or viral infections in these patient populations. This is because of the limited number of available therapies, dose-limiting toxicities of the antifungal drugs, fewer symptoms due to lack of inflammatory response, and the lack of sensitive tests to aid in the diagnosis of invasive fungal infections.1 A study of patients with fungal infections admitted to a university-affiliated hospital indicated that community-acquired infections are becoming a serious problem; 67% of the 140 patients had community-acquired fungal pneumonia.8