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Combination Antifungal Therapy in the Treatment of Scedosporium apiospermum Central Nervous System Infections. Case Rep Infect Dis 2013; 2013:589490. [PMID: 23738164 PMCID: PMC3657419 DOI: 10.1155/2013/589490] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 04/08/2013] [Indexed: 11/17/2022] Open
Abstract
Treatment of Scedosporium apiospermum central nervous system (CNS) infection typically consists of an azole in combination with surgical debridement. This approach requires prolonged treatment and carries a high associated mortality. We present two cases of the successful treatment of S. apiospermum CNS infections with the combination of voriconazole and terbinafine.
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Abstract
Scedosporium spp. are increasingly recognized as causes of resistant life-threatening infections in immunocompromised patients. Scedosporium spp. also cause a wide spectrum of conditions, including mycetoma, saprobic involvement and colonization of the airways, sinopulmonary infections, extrapulmonary localized infections, and disseminated infections. Invasive scedosporium infections are also associated with central nervous infection following near-drowning accidents. The most common sites of infection are the lungs, sinuses, bones, joints, eyes, and brain. Scedosporium apiospermum and Scedosporium prolificans are the two principal medically important species of this genus. Pseudallescheria boydii, the teleomorph of S. apiospermum, is recognized by the presence of cleistothecia. Recent advances in molecular taxonomy have advanced the understanding of the genus Scedosporium and have demonstrated a wider range of species than heretofore recognized. Studies of the pathogenesis of and immune response to Scedosporium spp. underscore the importance of innate host defenses in protection against these organisms. Microbiological diagnosis of Scedosporium spp. currently depends upon culture and morphological characterization. Molecular tools for clinical microbiological detection of Scedosporium spp. are currently investigational. Infections caused by S. apiospermum and P. boydii in patients and animals may respond to antifungal triazoles. By comparison, infections caused by S. prolificans seldom respond to medical therapy alone. Surgery and reversal of immunosuppression may be the only effective therapeutic options for infections caused by S. prolificans.
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Bates DD, Minis JW. Invasive Fungal Sinusitis Caused by Pseudallescheria Boydii: Case Report and Literature Review. EAR, NOSE & THROAT JOURNAL 2006. [DOI: 10.1177/014556130608501112] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fungal sinusitis secondary to Pseudallescheria boydii is rare, as only 25 cases have been previously reported in the literature. Although P boydii resembles Aspergillus on pathologic examination, it is typically resistant to amphotericin B. Therefore, culture is necessary to differentiate the two. Patients with P boydii sinusitis should generally be treated with a combination of surgery and antifungal therapy. Combination treatment is particularly important for immunocompromised patients with fungal invasion because mortality among these patients is high. The prognosis is better for immunocompetent patients, even those with fungal invasion. We describe a new case of invasive fungal sinusitis secondary to P boydii infection, and we review the literature on this emerging pathogen.
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Affiliation(s)
- Dwight D. Bates
- Department of Otolaryngology, Wake Forest University School of Medicine, Winston-Salem, N.C
| | - J. Whitman Minis
- Department of Otolaryngology, Wake Forest University School of Medicine, Winston-Salem, N.C
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Abstract
Since its discovery as an agent of mycetoma nearly a century ago, Pseudallescheria boydii with its asexual (synanamorphic) form, Scedosporium apiospermum, is now recognized as an important emerging opportunistic pathogen causing invasive mycosis in immunocompromised patients. The clinical spectrum of pseudallescheriasis is wide. Invasive disease of the lung, CNS and dissemination are serious manifestations in immunocompromised patients. This organism responds poorly to amphotericin B, and its histopathologic resemblance to aspergillosis often results in a delay in diagnosis. In vitro data, animal models and accumulating clinical experience support the use of voriconazole as a primary treatment for pseudallescheriasis. This paper reviews the microbiology, ecology, epidemiologic trends, clinical manifestations and current treatment options of pseudallescheriasis.
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Affiliation(s)
- Thomas A O'Bryan
- The Pennsylvania State University, College of Medicine, Hershey, PA 17033, USA.
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Husain S, Muñoz P, Forrest G, Alexander BD, Somani J, Brennan K, Wagener MM, Singh N. Infections Due to Scedosporium apiospermum and Scedosporium prolificans in Transplant Recipients: Clinical Characteristics and Impact of Antifungal Agent Therapy on Outcome. Clin Infect Dis 2005; 40:89-99. [PMID: 15614697 DOI: 10.1086/426445] [Citation(s) in RCA: 271] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2004] [Accepted: 09/01/2004] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Unique characteristics, impact of therapy with antifungal agents, and outcome of infections with Scedosporium species were assessed in transplant recipients. METHODS The patients comprised a total of 80 transplant recipients with Scedosporium infections, including 13 patients from our institutions (University of Pittsburgh Medical Center [Pittsburgh, PA], University of Maryland [Baltimore], Duke University Medical Center [Durham, NC], Emory University [Atlanta, GA], and Hospital Gregorio Maranon [Madrid, Spain]) and 67 reported in the literature. The transplant recipients were compared with 190 non-transplant recipients with scedosporiosis who were described in the literature. RESULTS Overall, 69% of the infections in hematopoietic stem cell transplant (HSCT) recipients and 53% of the infections in organ transplant recipients were disseminated. HSCT recipients, compared with organ transplant recipients, were more likely to have infections caused by Scedosporium prolificans (P=.045), to have an earlier onset of infection (P=.007), to be neutropenic (P<.0001), and to have fungemia (P=.04). Time elapsed from transplantation to Scedosporium infection in transplant recipients has increased in recent years (P=.002). The mortality rate among transplant recipients with scedosporiosis was 58%. In a logistic regression model using amphotericin B as comparison treatment, voriconazole was associated with a trend towards better survival (odds ratio [OR], 10.40; P=.08). Presence of disseminated infection (OR, 0.20; P=.03) predicted lower survival, and receipt of adjunctive surgery as treatment (OR, 5.52; P=.02) independently predicted a better survival in this model. CONCLUSIONS Scedosporium infections in transplant recipients were associated with a high rate of dissemination and a poor outcome overall. The use of newer triazole agents warrants consideration as a therapeutic modality for these infections.
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Affiliation(s)
- Shahid Husain
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Walsh TJ, Groll A, Hiemenz J, Fleming R, Roilides E, Anaissie E. Infections due to emerging and uncommon medically important fungal pathogens. Clin Microbiol Infect 2004; 10 Suppl 1:48-66. [PMID: 14748802 DOI: 10.1111/j.1470-9465.2004.00839.x] [Citation(s) in RCA: 374] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The emergence of less common but medically important fungal pathogens contributes to the rate of morbidity and mortality, especially in the increasingly expanding population of immunocompromised patients. These pathogens include septate filamentous fungi (e.g., Fusarium spp., Scedosporium spp., Trichoderma spp.), nonseptate Zygomycetes, the endemic dimorphic pathogen Penicillium marneffei, and non-Cryptococcus, non-Candida pathogenic yeast (e.g., Trichosporon spp.). The medical community is thus called upon to acquire an understanding of the microbiology, epidemiology and pathogenesis of these previously uncommon pathogens in order to become familiar with the options for prevention and treatment.
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Affiliation(s)
- T J Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, The National Cancer Institute, Bethesda, MD 20892-1928, USA.
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Abstract
During the past two decades opportunistic fungal infections have emerged as important causes of morbidity and mortality in patients with severe underlying illnesses and compromised host defenses. While Aspergillus and Candida spp. collectively account for the majority of these infections, recent epidemiological trends indicate a shift towards infections by Aspergillus spp., nonalbicans Candida spp., as well as previously uncommon opportunistic fungi. Apart from an expanding number of different Zygomycetes, previously uncommon hyaline filamentous fungi (such as Fusarium species, Acremonium species, Paecilomyces species, Pseudallescheria boydii, and Scedosporium prolificans), dematiaceous filamentous fungi (such as Bipolaris species, Cladophialophora bantiana, Dactylaria gallopava, Exophiala species, and Alternaria species) and yeast-like pathogens (such as Trichosporon species, Blastoschizomyces capitatus, Malassezia species, Rhodotorula rubra and others) are increasingly encountered as causing life threatening invasive infections that are often refractory to conventional therapies. On the basis of past and current trends, the spectrum of fungal pathogens will continue to evolve in the settings of an expanding population of immunocompromised hosts, selective antifungal pressures, and shifting conditions in hospitals and the environment. An expanded and refined drug arsenal, further elucidation of pathogenesis and resistance mechanisms, establishment of in vitro/in vivo correlations, incorporation of pharmacodynamics, combination- and immunotherapies offer hope for substantial progress in prevention and treatment.
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Affiliation(s)
- A H Groll
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD 20892, USA.
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Williamson EC, Speers D, Arthur IH, Harnett G, Ryan G, Inglis TJ. Molecular epidemiology of Scedosporium apiospermum infection determined by PCR amplification of ribosomal intergenic spacer sequences in patients with chronic lung disease. J Clin Microbiol 2001; 39:47-50. [PMID: 11136746 PMCID: PMC87677 DOI: 10.1128/jcm.39.1.47-50.2001] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Respiratory tract colonization with Scedosporium apiospermum in patients with chronic suppurative lung disease is a significant concern for lung transplantation candidates, since Scedosporium infections occurring posttransplantation are usually untreatable. Up to 10% of patients with cystic fibrosis attending our respiratory medicine unit have had Scedosporium organisms isolated from sputum samples. We therefore developed a molecular typing method to examine these isolates. Typing by PCR amplification of ribosomal intergenic spacer sequences demonstrated 20 different types from 52 isolates collected from the respiratory medicine unit and elsewhere in Australia. A single common type was isolated from 11 respiratory medicine unit inpatients. Two other types were isolated from more than one source: one from two respiratory medicine unit inpatients and one from two epidemiologically linked nonhuman sources. Multiple isolates were obtained from nine patients. This method demonstrated persistent carriage of isolates of the same type in one patient for 7 months. Two patients showed carriage of isolates with multiple typing patterns within a 3-month period. The high rate of isolation and the predominance of isolates with a single typing pattern from respiratory medicine unit patients may suggest transmission to patients from a source in the unit. There was no epidemiological evidence of direct patient-to-patient spread, and Scedosporium organisms were not isolated from dust, soil, or air samples from the unit. The source and route of transmission have yet to be determined.
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Affiliation(s)
- E C Williamson
- Division of Microbiology and Infectious Diseases, The Western Australian Center for Pathology and Medical Research (PathCentre), Nedlands 6009, Australia.
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Abstract
Treatments for the various kinds of fungal rhinosinusitis are fundamentally different, and it is essential to obtain an accurate diagnosis of the particular syndrome in a given case. Microscopic examination of specimens is the most definite and rapid means of establishing a diagnosis of fungal rhinosinusitis. This article compares the utility of various staining and microscopy methods, presents two keys for the algorithmic evaluation of fungal cells as seen in clinical specimens, discusses practical aspects of fungal spore formation within clinical specimens, and reevaluates the role of Candida albicans in rhinosinus disease.
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Affiliation(s)
- W A Schell
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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Walsh TJ, Groll AH. Emerging fungal pathogens: evolving challenges to immunocompromised patients for the twenty-first century. Transpl Infect Dis 1999; 1:247-61. [PMID: 11428996 DOI: 10.1034/j.1399-3062.1999.010404.x] [Citation(s) in RCA: 223] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Opportunistic fungi have emerged during the past decade as important causes of morbidity and mortality in immunocompromised patients. Candida species constitute the third to fourth most common causes of nosocomial blood stream infections, and Aspergillus species have emerged as the most common infectious cause of pneumonic mortality in bone marrow/stem cell transplant recipients. Among HIV-infected patients, meningoencephalitis due to Cryptococcus neoformans ranks among the most common AIDS-defining infections. Hyaline septated filamentous fungi, such as Fusarium species, Acremonium species, Paecilomyces species, and Trichoderma species, are increasingly reported as causing invasive mycoses refractory to conventional therapy. Dematiaceous septated filamentous fungi, such as Pseudallescheria boydii, Bipolaris species, and Cladophialophora bantiana cause pneumonia, sinusitis, and CNS infection unresponsive to current therapy. An increasing number of different members of the class of Zygomycetes are reported as causing lethal infections, despite aggressive medical and surgical interventions. Yet the treatment for zygomycosis has not changed in approximately 40 years. The prevalence of the endemic mycoses, such as those due to Penicillium marneffei, Coccidioides immitis, and Histoplasma capsulatum, has been reported to expand rapidly in response to environmental exposures and increased numbers of vulnerable hosts in endemic regions of the world. Dermatophytoses are occurring with increasing prevalence and morbidity in elderly and immunocompromised patients. As we enter the next millennium, we may anticipate that emergent fungal infections will continue to develop in the settings of permissive environmental conditions, selective antifungal pressure, and an expanding population of immunocompromised hosts.
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Affiliation(s)
- T J Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland 20892, USA.
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Machado CM, Martins MA, Heins-Vaccari EM, Lacaz CDS, Macedo MC, Castelli JB, Medeiros RS, Silva RL, Dulley FL. Scedosporium apiospermum sinusitis after bone marrow transplantation: report of a case. Rev Inst Med Trop Sao Paulo 1998; 40:321-3. [PMID: 10030078 DOI: 10.1590/s0036-46651998000500010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A forty-year-old man underwent an allogeneic BMT from his HLA identical sister. GvHD prophylaxis was done with cyclosporine (CyA), methotrexate and prednisone (PDN). On day +90 extensive GvHD was noted and higher doses of immunosuppressive drugs alternating CyA with PDN were initiated. Patient's follow-up was complicated by intermittent episodes of leukopenia and monthly episodes of sinusitis or pneumonia. One year after BMT, the patient developed hoarseness and nasal voice. No etiologic agent could be identified on a biopsy sample of the vocal chord. Upon tapering the doses of immunosuppressive drugs, the patient had worsening of chronic GvHD and was reintroduced on high doses of cyclosporine alternating with prednisone on day +550. Three months later, GvHD remained out of control and the patient was started on azathioprine. On day +700, hoarseness and nasal voice recurred. Another biopsy of the left vocal chord failed to demonstrate infection. Episodes of sinusitis became more frequent and azathioprine was withheld 3 months after it was started. One month later, the patient had bloody nasal discharge and surgical drainage of maxillary sinuses was performed. Histopathology showed hyphae and cultures grew Scedosporium apiospermum. Itraconazole 800 mg/day was initiated. The patient developed progressive respiratory failure and died 15 days later.
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Affiliation(s)
- C M Machado
- Mycology Laboratory, Instituto de Medicina Tropical de São Paulo, Brasil
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García-Arata MI, Otero MJ, Zomeño M, de la Figuera MA, de las Cuevas MC, López-Brea M. Scedosporium apiospermum pneumonia after autologous bone marrow transplantation. Eur J Clin Microbiol Infect Dis 1996; 15:600-3. [PMID: 8874080 DOI: 10.1007/bf01709371] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Although opportunistic infections after bone marrow transplantation (BMT) are very common, only five cases of Pseudallescheria boydii infection have been reported in the literature, two of which were autopsy findings. A case of Scedosporium apiospermum infection after BMT, treated initially with amphotericin B (total dose of 2.5 g) and then with itraconazole (for 25 days), is reported here. When the patient failed to improve, Scedosporium apiospermum pneumonia was diagnosed and therapy was changed. The patient was treated successfully with miconazole (600 mg/8h for 32 days) and ketoconazole (200 mg/8h for 7 days) plus surgery.
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Affiliation(s)
- M I García-Arata
- Clinical Microbiology Department, Hospital Ramón y Cajal, Madrid, Spain
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Matsumoto T, Ajello L, Matsuda T, Szaniszlo PJ, Walsh TJ. Developments in hyalohyphomycosis and phaeohyphomycosis. JOURNAL OF MEDICAL AND VETERINARY MYCOLOGY : BI-MONTHLY PUBLICATION OF THE INTERNATIONAL SOCIETY FOR HUMAN AND ANIMAL MYCOLOGY 1994; 32 Suppl 1:329-49. [PMID: 7722796 DOI: 10.1080/02681219480000951] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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