Paecilomyces lilacinus infection in a liver transplant patient: case report and review of the literature

Oral Fungal Alterations in Patients with COVID-19 and Recovered Patients

The oral bacteriome, gut bacteriome, and gut mycobiome are associated with coronavirus disease 2019 (COVID-19). However, the oral fungal microbiota in COVID-19 remains unclear. This article aims to characterize the oral mycobiome in COVID-19 and recovered patients. Tongue coating specimens of 71 COVID-19 patients, 36 suspected cases (SCs), 22 recovered COVID-19 patients, 36 SCs who recovered, and 132 controls from Henan are collected and analyzed using internal transcribed spacer sequencing. The richness of oral fungi is increased in COVID-19 versus controls, and beta diversity analysis reveals separate fungal communities for COVID-19 and control. The ratio of Ascomycota and Basidiomycota is higher in COVID-19, and the opportunistic pathogens, including the genera Candida, Saccharomyces, and Simplicillium, are increased in COVID-19. The classifier based on two fungal biomarkers is constructed and can distinguish COVID-19 patients from controls in the training, testing, and independent cohorts. Importantly, the classifier successfully diagnoses SCs with positive specific severe acute respiratory syndrome coronavirus 2 immunoglobulin G antibodies as COVID-19 patients. The correlation between distinct fungi and bacteria in COVID-19 and control groups is depicted.. These data suggest that the oral mycobiome may play a role in COVID-19.

Non-Aspergillus Hyaline Molds: A Host-Based Perspective of Emerging Pathogenic Fungi Causing Sinopulmonary Diseases

The incidence of invasive sino-pulmonary diseases due to non-Aspergillus hyaline molds is increasing due to an enlarging and evolving population of immunosuppressed hosts as well as improvements in the capabilities of molecular-based diagnostics. Herein, we review the following opportunistic pathogens known to cause sinopulmonary disease, the most common manifestation of hyalohyphomycosis: Fusarium spp., Scedosporium spp., Lomentospora prolificans, Scopulariopsis spp., Trichoderma spp., Acremonium spp., Paecilomyces variotii, Purpureocillium lilacinum, Rasamsonia argillacea species complex, Arthrographis kalrae, and Penicillium species. To facilitate an understanding of the epidemiology and clinical features of sino-pulmonary hyalohyphomycoses in the context of host immune impairment, we utilized a host-based approach encompassing the following underlying conditions: neutropenia, hematologic malignancy, hematopoietic and solid organ transplantation, chronic granulomatous disease, acquired immunodeficiency syndrome, cystic fibrosis, and healthy individuals who sustain burns, trauma, or iatrogenic exposures. We further summarize the pre-clinical and clinical data informing antifungal management for each pathogen and consider the role of adjunctive surgery and/or immunomodulatory treatments to optimize patient outcome.

Chronic subcutaneous infection of Purpureocillium lilacinum in an immunocompromised patient: Case report and review of the literature

Our case reports a 52-year-old woman who presented with Purpureocillium lilacinum skin infection after a renal transplantation. The diagnosis was difficult and this species exhibits many resistances to antifungal agents. The clinical history was marked by a relapse causes by a foreign body. Our case suggests that posaconazole may be an alternative to cure P. lilacinum infection, and that the surgical debridement, the identification and removal of a foreign body may improve the prognosis.

Complicated multiple organ infection of Purpureocillium lilacinum and varicella-zoster virus infection in a patient with Evans’ syndrome

Purpureocillium lilacinum (P lilacinum) is a rare pathogenic fungus, which mainly involves immunocompromised individuals. Here, we report a case of complicated multiple-organ infections involving skin, lungs, and spleen in a 63-year-old female with Evans’ syndrome after 9 months of glucocorticoid treatment. Microbial examinations of skin biopsy and blood samples revealed P lilacinum infections. Posaconazole was effective in this patient. During anti-fungi treatment, she developed varicella-zoster virus infection and was diagnosed through next-generation sequencing examination. In conclusion, P lilacinum may affect different organ systems and is susceptible to posaconazole treatment. The molecular-based methods like microbial cell-free DNA sequencing could provide accurate and timely identification of a wide range of infections.

Paecilomyces in an immune competent host

Paecilomyces species was first recognized to cause human disease in 1963. It is a rare cause of invasive fungal infection, with cases sporadically reported in immunocompromised patients. Here we report the first case of pulmonary Paecilomyces in an immunocompetent patient that was successfully treated with amphotericin B and posaconazole.

Isavuconazonium for the treatment of Purpureocillium lilacinum infection in a patient with pyoderma gangrenosum

Purpureocillium lilacinum is a rare but emerging pathogen in immunocompromised patients that primarily infects the skin and subcutaneous tissue. We present a novel case of Purpureocillium lilacinum infection in a patient with pyoderma gangrenosum who was successfully treated with isavuconazonium, followed by a literature review of 13 total cases of infection with Purpureocillium lilacinum gathered from a review of the PubMed database. Previous reports have utilized voriconazole, an antifungal with significant toxic side effects. Our case highlights the importance of culture and biopsy in patients with pyoderma gangrenosum who are unresponsive to standard treatment irrespective of pathergy risk.

Emerging fungal infections in solid organ transplant recipients: Guidelines of the American Society of Transplantation Infectious Diseases Community of Practice

These updated AST-IDCOP guidelines review the epidemiology, diagnosis, and management of emerging fungi after organ transplantation. Infections due to numerous generally innocuous fungi are increasingly recognized in solid organ transplant (SOT) recipients, comprising about 7%-10% of fungal infections in this setting. Such infections are collectively referred to as emerging fungal infections and include Mucormycetes, Fusarium, Scedosporium, and dematiaceous fungi among others. The causative organisms are diverse in their pathophysiology, uncommon in the clinical setting, have evolving nomenclature, and are often resistant to multiple commonly used antifungal agents. In recent years significant advances have been made in understanding of the epidemiology of these emerging fungal infections, with improved diagnosis and expanded treatment options. Still, treatment guidelines are generally informed by and limited to experience from cohorts of patients with hematological malignancies and/or solid and stem cell transplants. While multicenter randomized controlled trials are not feasible for these uncommon infections in SOT recipients, collaborative prospective studies can be valuable in providing information on the epidemiology, clinical manifestations, treatment strategies, and outcomes associated with the more commonly encountered infections.

MIC Distributions and Evaluation of Fungicidal Activity for Amphotericin B, Itraconazole, Voriconazole, Posaconazole and Caspofungin and 20 Species of Pathogenic Filamentous Fungi Determined Using the CLSI Broth Microdilution Method

For filamentous fungi (moulds), species-specific interpretive breakpoints and epidemiological cut-off values (ECVs) have only been proposed for a limited number of fungal species-antifungal agent combinations, with the result that clinical breakpoints are lacking for most emerging mould pathogens. In the current study, we have compiled minimum inhibitory concentration (MIC) data for 4869 clinical mould isolates and present full MIC distributions for amphotericin B, itraconazole, voriconazole, posaconazole, and caspofungin with these isolates which comprise 20 species/genera. In addition, we present the results of an assessment of the fungicidal activity of these same five antifungal agents against a panel of 123 mould isolates comprising 16 of the same species.

Retrospective case-series of Paecilomyces lilacinus ocular mycoses in Queensland, Australia

Background

The purpose of this study was to report: (1) the varying presentation of Paecilomyces ocular infections arising in Queensland; (2) the significance of immunosuppression as a primary determinant of disease; (3) the outcomes of voriconazole use; and (4) the ongoing need for both surgical and medical management of this devastating fungal infection.

Methods

A retrospective case series of 21 culture proven individuals participated in this series and were identified via a review of the pathology reporting system utilized in the Queensland public health system. All culture proven individuals were subjected to a systematic chart review.

Results

The primary risk factor for Paecilomyces lilacinus infection is immunosuppression with 81.25 % of individuals being on some form of immunosuppression (i.e. systemic or topical). Of the cases 71.43 % had an intact epithelial surface at the time of diagnosis, and 76 % had no previous ocular history. The final visual outcomes were nine cases with HM vision or worse, three cases with 6/48–6/60 vision, three cases 6/12–6/24, and six cases with 6/12 vision or better. Despite voriconazole use rates of greater than 80 %, protracted and poor treatment outcomes continue to be commonplace.

Conclusions

Paecilomyces lilacinus is a filamentous fungus that has a predilection for immunosuppressed individuals. Despite in vitro and case reports demonstrating the effectiveness of voriconazole poor outcomes continue to be seen.

ESCMID and ECMM joint guidelines on diagnosis and management of hyalohyphomycosis: Fusarium spp., Scedosporium spp. and others

Mycoses summarized in the hyalohyphomycosis group are heterogeneous, defined by the presence of hyaline (non-dematiaceous) hyphae. The number of organisms implicated in hyalohyphomycosis is increasing and the most clinically important species belong to the genera Fusarium, Scedosporium, Acremonium, Scopulariopsis, Purpureocillium and Paecilomyces. Severely immunocompromised patients are particularly vulnerable to infection, and clinical manifestations range from colonization to chronic localized lesions to acute invasive and/or disseminated diseases. Diagnosis usually requires isolation and identification of the infecting pathogen. A poor prognosis is associated with fusariosis and early therapy of localized disease is important to prevent progression to a more aggressive or disseminated infection. Therapy should include voriconazole and surgical debridement where possible or posaconazole as salvage treatment. Voriconazole represents the first-line treatment of infections due to members of the genus Scedosporium. For Acremonium spp., Scopulariopsis spp., Purpureocillium spp. and Paecilomyces spp. the optimal antifungal treatment has not been established. Management usually consists of surgery and antifungal treatment, depending on the clinical presentation.

Occurrence of fruiting structures allows determination of Purpureocillium lilacinum as an inciting agent of pleuritis and pneumonia in a loggerhead sea turtle (Caretta caretta) by histopathologic correlation to culture

Purpureocillium lilacinum and Beauveria bassiana were isolated from lung sampled at necropsy of a 12 year-old female loggerhead sea turtle (Caretta caretta) that had displayed abnormal buoyancy. Histopathologic evaluation revealed pleuritis and pneumonia with non-melanized, septate hyphae and fruiting structures identical to those of P. lilacinum. This case emphasizes the importance of a histological correlate to fungal culture when environmental fungi are isolated and demonstrates the infrequent phenomenon of fruiting or conidial production in tissue.

Emerging fungal infections in solid organ transplant recipients

The most important emerging and rare fungal pathogens in solid organ transplant recipients are the Zygomycetes, Scedosporium, Fusarium, and the dark molds. Factors affecting the emergence of these fungi include the combination of intensive immunosuppressive regimens with increasingly widespread use of long-term azole antifungal therapy; employment of aggressive diagnostic approaches (eg, sampling of bronchoalveolar lavage fluid); and changes in patients' interactions with the environment. This article reviews the epidemiology, microbiology, and clinical impact of emerging fungal infections in solid organ transplant recipients, and provides up-to-date recommendations on their treatment.

Use of voriconazole for the treatment of Paecilomyces lilacinus cutaneous infections: case presentation and review of published literature

The fungus Paecilomyces lilacinus is a rare but emerging pathogen that causes severe human infections, especially in immunocompromised hosts. It is an important organism to identify due to its poor susceptibility to conventional antifungal drugs, including amphotericin B, itraconazole, and fluconazole. Oculomycosis and cutaneous infections are the two most common manifestations of P. lilacinus infections. Voriconazole has been used successfully to treat P. lilacinus endophthalmitis, but reports of skin and soft tissue infections treated with voriconazole are limited to six prior publications. Our immunocompromised patient had a subcutaneous P. lilacinus infection successfully treated with 3 months of voriconazole therapy.

Polyphasic analysis of Purpureocillium lilacinum isolates from different origins and proposal of the new species Purpureocillium lavendulum

Purpureocillium is a genus recently proposed to accommodate Paecilomyces lilacinus, a well studied species that has biotechnological properties and an ability to cause human infections. Since contradictory data have been reported on the intraspecific genetic variability of P. lilacinum, we have carried out a polyphasic study of a set of clinical and environmental isolates of this species. Detailed morphological examination and sequence analysis of four different loci, including the ribosomal internal transcribed spacer, the domains D1 and D2 of the 28S rDNA, EF-1a and the largest subunit of RNA polymerase II (rpb1), showed that P. lilacinum formed a well supported phylogenetic clade with low intraspecific variability. The new species Purpureocillium lavendulum, which has vinaceous colonies similar to those of P. lilacinum, is proposed. It is characterized by the lack of growth at 35 C, the production of a yellow diffusible pigment and by subglobose or limoniform conidia.

Paecilomyces lilacinus causing debilitating sinusitis in an immunocompetent patient: a case report

Introduction

Since the discovery of the first documented case of Paecilomyces in 1963, only five cases of Paecilomyces sinusitis have been described to date and all of them have predisposing factors such as immunocompromised status or prior nasal surgery. We present the first case of Paecilomyces lilacinus sinusitis in a fit young woman with no identified predisposing factors. To the best of our knowledge, this is the first known case in the UK and in Europe.

Case presentation

A 20-year-old Iraqi woman who has lived in the UK for the past five years presented with rhinorrhea, hyposmia, and nasal obstruction. She was previously fit and well and had no significant medical history. Imaging revealed a fungal infection that was eventually revealed on cytological examination to be P. lilacinus.

Conclusions

P. lilacinus is both a difficult and important organism to identify because it has intrinsic anti-fungal resistance. In our case, the infection was severe and recurrent, and the organism demonstrated resistance to common oral anti-fungal agents. There was a delay in its diagnosis, owing to its similarity in appearance to Penicillium and a difficulty in distinguishing between the two without specialized knowledge of fungal taxonomy. In the field of otolaryngology, Paecilomyces is relatively unknown. Our intention is to raise awareness of this organism as well as to describe the challenges in its management.

Purpureocillium lilacinum as a cause of cavitary pulmonary disease: a new clinical presentation and observations on atypical morphologic characteristics of the isolate

The first case of cavitary pulmonary disease caused by Purpureocillium lilacinum is described. The isolate showed atypical microscopic characteristics similar to Acremonium and Fusarium spp., which necessitated molecular identification by sequencing of multiple conserved loci. The patient responded to voriconazole, reinforcing its therapeutic efficacy for P. lilacinum infections.

Nonneoplastic mucocutaneous lesions in organ transplant recipients

Nonneoplastic mucocutaneous lesions are frequent in organ transplant recipients. Many of them are caused by a direct toxicity of immunosuppressive drugs, in particular glucocorticoids and cyclosporine. The effects of these agents are dose- and time-dependent. Glucocorticoids can cause acne, Cushingoid appearance, irregular purpuric areas, friable skin, and wide and violaceous stripes. Cyclosporine can cause hypertrichosis, pilosebaceous lesions, and gum hypertrophy. Patients with esthetic changes may show poor adherence to treatment with these immunosuppressive agents that may lead to progressive graft dysfunction. Apart from this direct toxicity, vigorous immunosuppression may render the transplant recipients more susceptible to mucocutaneous infections. Fungal infection, viral warts, and bacterial folliculitis are the most frequent types of mucocutaneous infection. Some fungal infections, such as oral candidiasis and pityriasis versicolor, are relatively trivial, but other mycotic infections can cause severe or disfigurating lesions. Among viral infections, warts and condylomata caused by human papilloma virus are frequent and may favor the development of nonmelanoma skin cancer. Bacterial infections are usually trivial in the early period after transplantation, being represented almost exclusively by folliculitis. However, subcutaneous infections may cause a necrotizing fasciculitis which is a life-threatening disorder, usually sustained by polymicrobial pathogens.

Characteristics of Paecilomyces lilacinus infection comparing immunocompetent with immunosuppressed murine model

The characteristics of Paecilomyces lilacinus infection were evaluated using two murine experimental models: immunocompetent and immunosuppressed. The evaluation criteria for characteristics of infection were clinical signs, weight loss, survival rates, histopathological alterations and the number of viable fungal cells re-isolated from different organs; and those for immunological status were in vitro lymphoproliferative response, cell surface phenotyping and IFN-γ production. Morphological evaluation showed that P. lilacinus isolates presented morphological characteristics consistent with those described in the literature. The immunocompetent mice could be infected by the fungi, but they did not develop the disease, unlike the immunosuppressed mice, which showed clinical signs of mycosis in an environment of suppressed cellular immune response. The hypothesis of latent infection reactivation in mice was not confirmed. The difference observed in the infection rate of the two fungi isolates points to an intrinsic variation between strains of P. lilacinus and led us to hypothesise that even in the presence of immunosuppressed environment, the fungus virulence can play a role in the pathogenesis of hyalohyphomycosis.

Epidemiology of invasive mycoses in North America

The incidence of invasive mycoses is increasing, especially among patients who are immunocompromised or hospitalized with serious underlying diseases. Such infections may be broken into two broad categories: opportunistic and endemic. The most important agents of the opportunistic mycoses are Candida spp., Cryptococcus neoformans, Pneumocystis jirovecii, and Aspergillus spp. (although the list of potential pathogens is ever expanding); while the most commonly encountered endemic mycoses are due to Histoplasma capsulatum, Coccidioides immitis/posadasii, and Blastomyces dermatitidis. This review discusses the epidemiologic profiles of these invasive mycoses in North America, as well as risk factors for infection, and the pathogens' antifungal susceptibility.

Molds: hyalohyphomycosis, phaeohyphomycosis, and zygomycosis

Emerging fungi previously thought to be nonpathogenic are now recognized as playing a significant role in the increased incidence of invasive fungal disease. This change in the epidemiology of invasive fungal infections (IFIs) has occurred in the era of aggressive new therapies for hematopoietic stem cell transplantation and other malignancies that lead to profound immunosuppression for longer durations and has extended the survival of these critically ill patients. The significant morbidity and mortality associated with these infections is not only related to the host populations but to delayed recognition and diagnosis and high rates of resistance in some of these emerging pathogens to standard antifungal therapies.