1
|
Loreto ES, Tondolo JSM, Zanette RA. Treating Pythiosis with Antibacterial Drugs Targeting Protein Synthesis: An Overview. J Fungi (Basel) 2024; 10:234. [PMID: 38667905 PMCID: PMC11051233 DOI: 10.3390/jof10040234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/08/2024] [Accepted: 03/18/2024] [Indexed: 04/28/2024] Open
Abstract
This review article explores the effectiveness of antibacterial drugs that inhibit protein synthesis in treating pythiosis, a difficult-to-treat infection caused by Pythium insidiosum. The article highlights the susceptibility of P. insidiosum to antibacterial drugs, such as macrolides, oxazolidinones, and tetracyclines. We examine various studies, including in vitro tests, experimental infection models, and clinical case reports. Based on our synthesis of these findings, we highlight the potential of these drugs in managing pythiosis, primarily when combined with surgical interventions. The review emphasizes the need for personalized treatment strategies and further research to establish standardized testing protocols and optimize therapeutic approaches.
Collapse
Affiliation(s)
- Erico S. Loreto
- Sobresp Faculty of Health Sciences, 520 Appel Street, Santa Maria 97015-030, RS, Brazil;
| | - Juliana S. M. Tondolo
- Sobresp Faculty of Health Sciences, 520 Appel Street, Santa Maria 97015-030, RS, Brazil;
| | - Régis A. Zanette
- Department of Pharmacology, Basic Health Sciences Institute, Federal University of Rio Grande do Sul, 2600 Ramiro Barcelos Street, Porto Alegre 90035-003, RS, Brazil;
| |
Collapse
|
2
|
Ong HS, Sharma N, Phee LM, Mehta JS. Atypical microbial keratitis. Ocul Surf 2023; 28:424-439. [PMID: 34768003 DOI: 10.1016/j.jtos.2021.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 01/16/2023]
Abstract
Atypical microbial keratitis refers to corneal infections caused by micro-organisms not commonly encountered in clinical practice. Unlike infections caused by common bacteria, cases of atypical microbial keratitis are often associated with worse clinical outcomes and visual prognosis. This is due to the challenges in the identification of causative organisms with standard diagnostic techniques, resulting in delays in the initiation of appropriate therapies. Furthermore, due to the comparatively lower incidence of atypical microbial keratitis, there is limited literature on effective management strategies for some of these difficult to manage corneal infections. This review highlights the current management and available evidence of atypical microbial keratitis, focusing on atypical mycobacteria keratitis, nocardia keratitis, achromobacter keratitis, and pythium keratitis. It will also describe the management of two uncommonly encountered conditions, infectious crystalline keratopathy and post-refractive infectious keratitis. This review can be used as a guide for clinicians managing patients with such challenging corneal infections.
Collapse
Affiliation(s)
- Hon Shing Ong
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore; Tissue Engineering and Cell Therapy Department, Singapore Eye Research Institute, Singapore; Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore.
| | - Namrata Sharma
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Lynette M Phee
- Department of Pathology, Sengkang General Hospital, SingHealth, Singapore
| | - Jodhbir S Mehta
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore; Tissue Engineering and Cell Therapy Department, Singapore Eye Research Institute, Singapore; Department of Ophthalmology and Visual Science, Duke-National University of Singapore (NUS) Graduate Medical School, Singapore; School of Material Science & Engineering and School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore.
| |
Collapse
|
3
|
Cao B, Gonugunta VT, Radhakrishnan N, Lalitha P, Gurnani B, Kaur K, Iyer G, Agarwal S, Srinivasan B, Keenan JD, Prajna NV. Outcomes of Pythium keratitis: a meta-analysis of individual patient data. CURRENT OPHTHALMOLOGY REPORTS 2022; 10:198-208. [PMID: 37250102 PMCID: PMC10211475 DOI: 10.1007/s40135-022-00302-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
Background Pythium keratitis is a difficult-to-treat corneal infection. Methods A meta-analysis of individual patient data from observational studies of Pythium keratitis was performed. The outcomes of interest were therapeutic penetrating keratoplasty (TPK) and globe removal (evisceration, enucleation, or exenteration); the main exposures were linezolid and azithromycin use. Findings Of 46 eligible articles, individual patient data were available for 306 eyes (34 studies). Pythium keratitis was associated with high rates of TPK (80%, 95%CI 70-87%) and globe removal (25%, 95%CI 13-43). In multivariable models adjusting for age and country, fewer TPKs were performed in patients treated with azithromycin (RR=0.80, 95%CI 0.67-0.96; P=0.04) and linezolid (RR=0.82, 95%CI 0.67-0.99; P=0.02). Conclusions Studies of Pythium keratitis reported high rates of TPK and globe removal. Use of azithromycin and linezolid was associated with a lower rate of TPK. While promising, these results should be interpreted with caution given the biases inherent to observational studies.
Collapse
Affiliation(s)
- Binh Cao
- Francis I Proctor Foundation, University of California, San Francisco, USA
| | | | - Naveen Radhakrishnan
- Department of Cornea and Refractive Surgery, Aravind Eye Hospital Madurai, India
| | - Prajna Lalitha
- Department of Ocular Microbiology, Aravind Eye Hospital Madurai, India
| | - Bharat Gurnani
- Dr. Om Parkash Eye Institute, Amritsar, India
- Aravind Eye Hospital and Post Graduate Institute, Pondicherry, India
| | - Kirandeep Kaur
- Dr. Om Parkash Eye Institute, Amritsar, India
- Aravind Eye Hospital and Post Graduate Institute, Pondicherry, India
| | - Geetha Iyer
- C J Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, Chennai, India
| | - Shweta Agarwal
- C J Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, Chennai, India
| | - Bhaskar Srinivasan
- C J Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, Chennai, India
| | - Jeremy D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, USA
- Department of Ophthalmology, University of California, San Francisco, USA
| | - N Venkatesh Prajna
- Department of Cornea and Refractive Surgery, Aravind Eye Hospital Madurai, India
| |
Collapse
|
4
|
Gurnani B, Kaur K, Agarwal S, Lalgudi VG, Shekhawat NS, Venugopal A, Tripathy K, Srinivasan B, Iyer G, Gubert J. Pythium insidiosum Keratitis: Past, Present, and Future. Ophthalmol Ther 2022; 11:1629-1653. [PMID: 35788551 PMCID: PMC9255487 DOI: 10.1007/s40123-022-00542-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/15/2022] [Indexed: 11/30/2022] Open
Abstract
Pythium insidiosum (PI) is an oomycete, a protist belonging to the clade Stramenopila. PI causes vision-threatening keratitis closely mimicking fungal keratitis (FK), hence it is also labeled as "parafungus". PI keratitis was initially confined to Thailand, USA, China, and Australia, but with growing clinical awareness and improvement in diagnostic modalities, the last decade saw a massive upsurge in numbers with the majority of reports coming from India. In the early 1990s, pythiosis was classified as vascular, cutaneous, gastrointestinal, systemic, and ocular. Clinically, morphologically, and microbiologically, PI keratitis closely resembles severe FK and requires a high index of clinical suspicion for diagnosis. The clinical features such as reticular dot infiltrate, tentacular projections, peripheral thinning with guttering, and rapid limbal spread distinguish it from other microorganisms. Routine smearing with Gram and KOH stain reveals perpendicular septate/aseptate hyphae, which closely mimic fungi and make the diagnosis cumbersome. The definitive diagnosis is the presence of dull grey/brown refractile colonies along with zoospore formation upon culture by leaf induction method. However, culture is time-consuming, and currently polymerase chain reaction (PCR) method is the gold standard. The value of other diagnostic modalities such as confocal microscopy and immunohistopathological assays is limited due to cost, non-availability, and limited diagnostic accuracy. PI keratitis is a relatively rare disease without established treatment protocols. Because of its resemblance to fungus, it was earlier treated with antifungals but with an improved understanding of its cell wall structure and absence of ergosterol, this is no longer recommended. Currently, antibacterials have shown promising results. Therapeutic keratoplasty with good margin (1 mm) is mandated for non-resolving cases and corneal perforation. In this review, we have deliberated on the evolution of PI keratitis, covered all the recently available literature, described our current understanding of the diagnosis and treatment, and the potential future diagnostic and management options for PI keratitis.
Collapse
Affiliation(s)
- Bharat Gurnani
- Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, 605007, India.
| | - Kirandeep Kaur
- Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, 605007 India
| | - Shweta Agarwal
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, 18 College Road, Chennai, Tamil Nadu 600006 India
| | | | - Nakul S. Shekhawat
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Anitha Venugopal
- Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu India
| | | | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, 18 College Road, Chennai, Tamil Nadu 600006 India
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, 18 College Road, Chennai, Tamil Nadu 600006 India
| | - Joseph Gubert
- Department of Microbiology, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, 605007 India
| |
Collapse
|
5
|
Chatterjee S, Agrawal D, Gomase SN. Clinical differentiation of Pythium keratitis from fungal keratitis and development of a scoring system. Indian J Ophthalmol 2022; 70:3515-3521. [PMID: 36190038 PMCID: PMC9789832 DOI: 10.4103/ijo.ijo_870_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose To differentiate Pythium keratitis from fungal keratitis using clinical signs, to explore usefulness of various signs as diagnostic prognosticators, and develop a clinical scoring system. Methods A retrospective review of medical records and archived clinical photographs of patients with culture-positive Pythium keratitis and hyaline filamentous fungal keratitis was conducted at a tertiary eye institute to explore characteristics of ulcers that may aid diagnosis. Results Full-thickness corneal stromal keratitis (P = 0.055), a dry ulcer surface (P = 0.010), tentacles (P < 0.0001), intrastromal dots (P < 0.0001), ring infiltrates (P = 0.024), reticular patterns (P < 0.0001), and peripheral furrows (P < 0.0001) were clinical signs associated with Pythium keratitis. Multiple regression analysis identified tentacles (odds ratio: 24.1, 95% confidence interval (CI): 3.8-158.1, P = 0.001) and peripheral furrows (odds ratio: 60.6, 95% CI: 5.1-712.3, P = 0.001) as independent diagnostic prognosticators for Pythium keratitis. The positive and negative likelihood ratios of a dry ulcer surface, tentacles, intrastromal dots, ring infiltrates, reticular patterns, and peripheral furrows predicting Pythium keratitis were 1.6, 13.6, 17.9, 4.3, 30.7, 15.3 and 0.4, 0.4, 0.7, 0.9, 0.6 and 0.8, respectively. The presence of two or more of these clinical signs (excluding a dry ulcer surface) had a sensitivity of 55.6% and a false positive rate of 1.4%. Conclusion Tentacles, intrastromal dots, ring infiltrates, reticular patterns, and peripheral furrows are clinical signs to be considered for the diagnosis of Pythium keratitis and the presence of two or more signs has a very low false positive rate.
Collapse
Affiliation(s)
- Samrat Chatterjee
- Cornea and Anterior Segment Services, MGM Eye Institute, Raipur, Chhattisgarh, India,Correspondence to: Dr. Samrat Chatterjee, Cornea and Anterior Segment Services, MGM Eye Institute, 5th Mile, Vidhan Sabha Road, Raipur - 493 111, Chhattisgarh, India. E-mail:
| | - Deepshikha Agrawal
- Cornea and Anterior Segment Services, MGM Eye Institute, Raipur, Chhattisgarh, India
| | | |
Collapse
|
6
|
Gurnani B, Kaur K, Venugopal A, Srinivasan B, Bagga B, Iyer G, Christy J, Prajna L, Vanathi M, Garg P, Narayana S, Agarwal S, Sahu S. Pythium insidiosum keratitis - A review. Indian J Ophthalmol 2022; 70:1107-1120. [PMID: 35325996 PMCID: PMC9240499 DOI: 10.4103/ijo.ijo_1534_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Pythium insidiosum is an oomycete and is also called “parafungus” as it closely mimics fungal keratitis. The last decade saw an unprecedented surge in Pythium keratitis cases, especially from Asia and India, probably due to growing research on the microorganism and improved diagnostic and treatment modalities. The clinical features such as subepithelial infiltrate, cotton wool-like fluffy stromal infiltrate, satellite lesions, corneal perforation, endoexudates, and anterior chamber hypopyon closely resemble fungus. The classical clinical features of Pythium that distinguish it from other microorganisms are reticular dots, tentacular projections, peripheral furrowing, and early limbal spread, which require a high index of clinical suspicion. Pythium also exhibits morphological and microbiological resemblance to fungus on routine smearing, revealing perpendicular or obtuse septate or aseptate branching hyphae. Culture on blood agar or any other nutritional agar is the gold standard for diagnosis. It grows as cream-colored white colonies with zoospores formation, further confirmed using the leaf incarnation method. Due to limited laboratory diagnostic modalities and delayed growth on culture, there was a recent shift toward various molecular diagnostic modalities such as polymerase chain reaction, confocal microscopy, ELISA, and immunodiffusion. As corneal scraping (10% KOH, Gram) reveals fungal hyphae, antifungals are started before the culture results are available. Recent in vitro molecular studies have suggested antibacterials as the first-line drugs in the form of 0.2% linezolid and 1% azithromycin. Early therapeutic keratoplasty is warranted in nonresolving cases. This review aims to describe the epidemiology, clinical features, laboratory and molecular diagnosis, and treatment of Pythium insidiosum keratitis.
Collapse
Affiliation(s)
- Bharat Gurnani
- Cataract, Cornea, External Disease, Trauma and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Kirandeep Kaur
- Pediatric and Squint Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Anitha Venugopal
- Cornea, Ocular surface, Trauma and Refractive services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
| | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Bhupesh Bagga
- Cornea Clinic, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Josephine Christy
- Cataract, Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Lalitha Prajna
- Microbiology Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Murugesan Vanathi
- Cornea and Ocular Surface, Cataract and Refractive Services, Dr R P Centre, AIIMS, New Delhi, India
| | - Prashant Garg
- Director and Kallam Anji Reddy Chair of Ophthalmology Paul Dubord Chair of Cornea, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India
| | - Shivanand Narayana
- Cataract, Cornea, External Diseases, Trauma and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Shweta Agarwal
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Srikant Sahu
- Cornea and Anterior Segment, Contact Lens, Cataract, Laser Refractive Surgery Services, Mithu Tulsi Chanrai Campus, LV Prasad Eye Institute, Bhubaneswar, Orissa, India
| |
Collapse
|
7
|
History and Perspective of Immunotherapy for Pythiosis. Vaccines (Basel) 2021; 9:vaccines9101080. [PMID: 34696188 PMCID: PMC8539095 DOI: 10.3390/vaccines9101080] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/27/2021] [Accepted: 09/08/2021] [Indexed: 12/24/2022] Open
Abstract
The fungus-like microorganism Pythium insidiosum causes pythiosis, a life-threatening infectious disease increasingly reported worldwide. Antimicrobial drugs are ineffective. Radical surgery is an essential treatment. Pythiosis can resume post-surgically. Immunotherapy using P. insidiosum antigens (PIA) has emerged as an alternative treatment. This review aims at providing up-to-date information of the immunotherapeutic PIA, with the focus on its history, preparation, clinical application, outcome, mechanism, and recent advances, in order to promote the proper use and future development of this treatment modality. P. insidiosum crude extract is the primary source of immunotherapeutic antigens. Based on 967 documented human and animal (mainly horses) pythiosis cases, PIA immunotherapy reduced disease morbidity and mortality. Concerning clinical outcomes, 19.4% of PIA-immunized human patients succumbed to vascular pythiosis instead of 41.0% in unimmunized cases. PIA immunotherapy may not provide an advantage in a local P. insidiosum infection of the eye. Both PIA-immunized and unimmunized horses with pythiosis showed a similar survival rate of ~70%; however, demands for surgical intervention were much lesser in the immunized cases (22.8% vs. 75.2%). The proposed PIA action involves switching the non-protective T-helper-2 to protective T-helper-1 mediated immunity. By exploring the available P. insidiosum genome data, synthetic peptides, recombinant proteins, and nucleic acids are potential sources of the immunotherapeutic antigens worth investigating. The PIA therapeutic property needs improvement for a better prognosis of pythiosis patients.
Collapse
|
8
|
Anitha V, Vanathi M. Commentary: A retrospective multifactorial analysis of Pythium keratitis and review of the literature. Indian J Ophthalmol 2021; 69:1101-1102. [PMID: 33913841 PMCID: PMC8186635 DOI: 10.4103/ijo.ijo_3660_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Venugopal Anitha
- Senior Cornea Consultant, Aravind Eye Hospitals and Postgraduate Institute, Tirunelveli, Tamil Nadu, India
| | - Murugesan Vanathi
- Cornea, Cataract and Refractive Surgery Services - Dr. R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
9
|
Predisposing Factors, Clinical Presentations, and Outcomes of Contact Lens-Related Pythium Keratitis. Cornea 2021; 40:1413-1419. [PMID: 33470674 DOI: 10.1097/ico.0000000000002651] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/24/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe predisposing factors, clinical presentations, and treatment outcomes of contact lens (CL)-related Pythium keratitis. METHODS This was an 11-year retrospective study of CL-related Pythium keratitis conducted from 2009 to 2019. Six eyes of 6 patients were identified. Demographics, predisposing factors, CL history, clinical presentation, diagnostic tests, treatments, and outcomes were reviewed. RESULTS Mean age of the patients was 34 years (SD 16.3 years) with equal proportion between male and female patients. Five of 6 patients (83.3%) used soft CL, whereas 1 patient used rigid gas permeable lens. All patients had a history of water contamination (tap water and water from river and sea). Mean duration from the onset was 7.8 days (range 4-14 days). Mean size of the corneal lesion was 3.33 mm (SD 1.31 mm) in width. The typical feature of tentacle-like lesions radiating in a reticular pattern was observed in all patients. Feathery edge (1 eye), satellite lesions (2 eyes), and radial keratoneuritis (2 eyes) were also found. Every patient received therapeutic penetrating keratoplasty because of failed medical treatments. One patient subsequently underwent enucleation. Globe salvage was achieved in 5 patients (83.33%). CONCLUSIONS Awareness of the history of water contamination, recognition of specific clinical features of Pythium keratitis, and performing surgical treatment are key for achieving globe salvage in patients with CL-related Pythium keratitis.
Collapse
|
10
|
Appavu SP, Prajna L, Rajapandian SGK. Genotyping and phylogenetic analysis of Pythium insidiosum causing human corneal ulcer. Med Mycol 2020; 58:211-218. [PMID: 31073609 DOI: 10.1093/mmy/myz044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/21/2019] [Accepted: 04/11/2019] [Indexed: 11/13/2022] Open
Abstract
Pythium insidiosum belongs to the Oomycetes, which are known to cause serious life-threatening infectious condition in humans and animals. Corneal infections caused by P. insidiosum are rare and difficult to treat. The molecular-based diagnosis of Pythium is employed for the species identification and to study molecular phylogenetic relationship. Based on Cytochrome oxidase II (cox II) gene, P. insidiosum is categorized into three clades or groups: Clade-I or ATH (American strains), Clade-II or BTH (American, Asian, and Australian strains), and Clade-III or CTH (mostly Thailand strains). This study focused on the molecular identification of Pythium insidiosum from patients with corneal ulcer using ITS regions and clade identification by cox II gene sequencing and correlated with the clinical outcome. The isolates were collected from Aravind Eye Hospital, Madurai, India, from April to December 2018. Through the microbiological laboratory reports, 15 isolates of Pythium sp. from keratitis patient were selected, followed by DNA extraction, ITS, and cox II gene sequencing and phylogenetic analysis using the reference sequences from NCBI database. All 15 P. insidiosum isolates were phylogenetically clustered together as a single group and where also placed distantly from other Pythium species (outgroup). Most ocular isolates fell into either clade BTH or clade CTH, and none of our ocular isolates were in clade ATH. Two of the strains were very distinct and did not match any of the clusters indicating different lineages. There was no significant difference between clinical outcome and genotype of P. insidiosum.
Collapse
Affiliation(s)
| | - Lalitha Prajna
- Department of Microbiology, Aravind Eye Hospital, Madurai
| | | |
Collapse
|
11
|
Yolanda H, Krajaejun T. Review of methods and antimicrobial agents for susceptibility testing against Pythium insidiosum. Heliyon 2020; 6:e03737. [PMID: 32322727 PMCID: PMC7160450 DOI: 10.1016/j.heliyon.2020.e03737] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/30/2020] [Accepted: 03/31/2020] [Indexed: 12/19/2022] Open
Abstract
Pythiosis is a life-threatening infectious disease of humans and animals caused by the oomycete microorganism Pythium insidiosum. The disease has been increasingly diagnosed worldwide. P. insidiosum inhabits freshwater and presents in two forms: mycelium and zoospore. Clinical manifestations of pythiosis include an infection of the artery, eye, skin, or gastrointestinal tract. The management of pythiosis is problematic due to the lack of effective treatment. Many patients die from an uncontrolled infection. The drug susceptibility testing provides clinically-useful information that could lead to proper drug selection against P. insidiosum. Currently, no standard CLSI protocol for the drug susceptibility of P. insidiosum is available. This review aims at describing methods and antimicrobial agents for susceptibility testing against P. insidiosum. Several in-house in vitro susceptibility methods (i.e., broth microdilution method, radial growth method, and agar diffusion method) have been established for P. insidiosum. Either mycelium or zoospore can be an inoculum. Rabbit is the commonly-used model of pythiosis for in vivo drug susceptibility testing. Based on the susceptibility results (i.e., minimal inhibitory concentration and inhibition zone), several antibacterial and antifungal drugs, alone or combination, exhibited an in vitro or in vivo effect against P. insidiosum. Some distinct compounds, antiseptic agents, essential oils, and plant extracts, also show anti-P. insidiosum activities. Successfully medical treatment, guided by the drug susceptibility data, has been reported in some pythiosis patients. Future studies should emphasize finding a novel and effective anti-P. insidiosum drug, standardizing in vitro susceptibility method and correlating drug susceptibility data and clinical outcome of pythiosis patients for a better interpretation of the susceptibility results.
Collapse
Affiliation(s)
- Hanna Yolanda
- Section for Translational Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Parasitology, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Theerapong Krajaejun
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
12
|
Chitasombat MN, Jongkhajornpong P, Lekhanont K, Krajaejun T. Recent update in diagnosis and treatment of human pythiosis. PeerJ 2020; 8:e8555. [PMID: 32117626 PMCID: PMC7036273 DOI: 10.7717/peerj.8555] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/13/2020] [Indexed: 12/20/2022] Open
Abstract
Human pythiosis is an infectious condition with high morbidity and mortality. The causative agent is the oomycete microorganism Pythium insidiosum. The pathogen inhabits ubiquitously in a wet environment, and direct exposure to the pathogen initiates the infection. Most patients with pythiosis require surgical removal of the affected organ, and many patients die from the disease. Awareness of pythiosis among healthcare personnel is increasing. In this review, we summarized and updated information on the diagnosis and treatment of human pythiosis. Vascular and ocular pythiosis are common clinical manifestations. Recognition of the typical clinical features of pythiosis is essential for early diagnosis. The definitive diagnosis of the disease requires laboratory testing, such as microbiological, serological, molecular, and proteomic assays. In vascular pythiosis, surgical intervention to achieve the organism-free margin of the affected tissue, in combination with the use of antifungal drugs and P. insidiosum immunotherapy, remains the recommended treatment. Ocular pythiosis is a serious condition and earliest therapeutic penetrating keratoplasty with wide surgical margin is the mainstay treatment. Thorough clinical assessment is essential in all patients to evaluate the treatment response and detect an early sign of the disease recurrence. In conclusion, early diagnosis and proper management are the keys to an optimal outcome of the patients with pythiosis.
Collapse
Affiliation(s)
- Maria Nina Chitasombat
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Passara Jongkhajornpong
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kaevalin Lekhanont
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Theerapong Krajaejun
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
13
|
Worasilchai N, Leelahavanichkul A, Permpalung N, Kuityo C, Phaisanchatchawan T, Palaga T, Reantragoon R, Chindamporn A. Antigen host response differences between the animal-type strain and human-clinical Pythium insidiosum isolates used for serological diagnosis in Thailand. Med Mycol 2019; 57:519-522. [PMID: 30165659 DOI: 10.1093/mmy/myy072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/20/2018] [Accepted: 07/28/2018] [Indexed: 11/13/2022] Open
Abstract
The detection of Pythium insidiosum-specific-immunoglobulin-G antibody (Pi-Ab) with enzyme-linked immunosorbent assay (ELISA) test depends on the source of antigen. In this study, the Pi-Ab levels in 140 serum samples from patients with pythiosis were evaluated by ELISA using antigens from 10 P. insidiosum clinical isolates in comparison with antigen from the equine-standard-type strain. The ELISA values (EVs), calculated from antibody levels from serum of patients with pythiosis or other infections versus healthy controls, were significantly higher in the test with clinical-isolates antigen than the standard-equine-type strain (6.0 ± 2.6 vs 4.0 ± 1.7, respectively; P < .0001). ELISA with antigen from human source might be more proper diagnosis test.
Collapse
Affiliation(s)
- N Worasilchai
- Interdisciplinary Program, Medical Microbiology, Graduate school, Chulalongkorn University, Bangkok, Thailand
| | - A Leelahavanichkul
- Division of Immunology, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - N Permpalung
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - C Kuityo
- Interdisciplinary Program, Medical Microbiology, Graduate school, Chulalongkorn University, Bangkok, Thailand
| | - T Phaisanchatchawan
- Interdisciplinary Program, Medical Microbiology, Graduate school, Chulalongkorn University, Bangkok, Thailand
| | - T Palaga
- Department of Microbiology, Faculty of Science, Chulalongkorn University, Bangkok, Thailand
| | - R Reantragoon
- Division of Immunology, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence in Immunology and Immune-mediated diseases, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - A Chindamporn
- Division of Mycology, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
14
|
Raghavan A, Bellamkonda P, Mendoza L, Rammohan R. Pythium insidiosum and Acanthamoeba keratitis in a contact lens user. BMJ Case Rep 2018; 11:11/1/bcr-2018-226386. [PMID: 30567163 DOI: 10.1136/bcr-2018-226386] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The oomycete Pythium and the protozoan Acanthamoeba can cause fulminant and recalcitrant keratitis, respectively. These infections are not only sight-threatening but can also threaten the structural integrity of the eye. A high index of suspicion is required to identify Pythium keratitis given its uncommon occurrence. Acanthamoeba keratitis is most commonly associated with contact lens wear. However, its coexistence with Pythium has not been reported. We present the successful management of a case of contact lens-related keratitis, coinfected with Pythium and Acanthamoeba.
Collapse
Affiliation(s)
- Anita Raghavan
- Cornea and Refractive Services, Aravind Eye Hospital Coimbatore, Coimbatore, Tamil Nadu, India
| | - Prathyusha Bellamkonda
- Cornea and Refractive Services, Aravind Eye Hospital Coimbatore, Coimbatore, Tamil Nadu, India
| | - Leonel Mendoza
- Microbiology, Michigan State University, East Lansing, Michigan, USA
| | - Ram Rammohan
- Microbiology, Aravind Eye Hospital Coimbatore, Coimbatore, Tamil Nadu, India
| |
Collapse
|
15
|
Agarwal S, Iyer G, Srinivasan B, Benurwar S, Agarwal M, Narayanan N, Lakshmipathy M, Radhika N, Rajagopal R, Krishnakumar S, K LT. Clinical profile, risk factors and outcome of medical, surgical and adjunct interventions in patients with Pythium insidiosum keratitis. Br J Ophthalmol 2018; 103:296-300. [PMID: 30206158 DOI: 10.1136/bjophthalmol-2017-311804] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/05/2018] [Accepted: 08/20/2018] [Indexed: 11/04/2022]
Abstract
PURPOSE To report clinical profile and compare management options for Pythium keratitis. METHOD Retrospective interventional study of 46 patients diagnosed as Pythium keratitis by PCR DNA sequencing from January 2014 to July 2017. Interventions were categorised into medical management (MM) (topical azithromycin and linezolid with oral azithromycin at presentation), surgery (S) (therapeutic penetrating keratoplasty, TPK), surgical adjunct (SA) (cryotherapy±alcohol with TPK) and medical adjunct (MA) (MM after TPK). RESULTS Primary treatment included MM (1 eye), SA (3 eyes) and S (42 eyes). Recurrence occurred in 27/43 eyes (MM+S group). Second surgery (S) was required in 11 eyes (TPK-2), with additional procedures (SA) in 10 eyes and evisceration in five eyes. 8/43 eyes received MA after TPK-1. One eye required TPK-3. Recurrence occured in all eyes that received MA (100%) and in 28 of 54 TPKs (51.8%) (TPK 1+2+3) in 42 eyes. Recurrence was noted in 1/14 (7.1%) that underwent SA. CONCLUSION The currently available and recommended treatment for Pythium keratitis is surgical by means of a TPK and in worse cases evisceration. In our study, MM/MA measures showed no benefit with recurrence or worsening of infection requiring resurgery. Almost 50% of TPKs had a recurrence requiring resurgery. However, adjunctive procedures during TPK appear to have additional benefit with low risk of recurrence and could be included as routine care.
Collapse
Affiliation(s)
- Shweta Agarwal
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - Geetha Iyer
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - Bhaskar Srinivasan
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - Saket Benurwar
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - Mamta Agarwal
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - Niveditha Narayanan
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - Meena Lakshmipathy
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - N Radhika
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - Rama Rajagopal
- CJ Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Chennai, Tamil Nadu, India
| | - S Krishnakumar
- L&T Ophthalmic Pathology Department, Vision Research Foundation, Chennai, Tamil Nadu, India
| | - Lily Therese K
- L&T Microbiology Research Centre, Vision Research Foundation, Chennai, Tamil Nadu, India
| |
Collapse
|
16
|
Monitoring Anti-Pythium insidiosum IgG Antibodies and (1→3)-β-d-Glucan in Vascular Pythiosis. J Clin Microbiol 2018; 56:JCM.00610-18. [PMID: 29848566 DOI: 10.1128/jcm.00610-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/22/2018] [Indexed: 11/20/2022] Open
Abstract
Despite aggressive treatment, vascular pythiosis has a mortality rate of 40%. This is due to delays in diagnosis and a lack of effective monitoring tools. To overcome this drawback, serum beta-d-glucan (BG) and P. insidiosum-specific antibody (Pi-Ab) were examined as potential monitoring markers in vascular pythiosis. A prospective cohort study of vascular pythiosis patients was carried out from January 2010 to July 2016. Clinical information and blood samples were collected and evaluated by the BG and Pi-Ab assays. Linear mixed-effect models were used to compare BG and Pi-Ab levels. The in vitro susceptibility test was performed with all P. insidiosum isolates from culture-positive cases. A total of 50 patients were enrolled: 45 survived and 5 died during follow-up. The survivors had a significantly shorter time to medical care (P < 0.0001) and a significantly shorter waiting time to the first surgery (P < 0.0001). There were no differences in BG levels among the groups at diagnosis (P = 0.33); however, BG levels among survivors were significantly lower than those of the deceased group at 0.5 months (P < 0.0001) and became undetectable after 3 months. Survivors were able to maintain an enzyme-linked immunosorbent assay (ELISA) value (EV) of Pi-Ab above 8, whereas the EV among deceased patients was less than 4. In vitro susceptibility results revealed no synergistic effects between itraconazole and terbinafine. This study showed that BG and Pi-Ab are potentially valuable markers to monitor the disease after treatment initiation. An unchanged BG level at 2 weeks after surgery should prompt an evaluation for residual disease.
Collapse
|
17
|
He H, Liu H, Chen X, Wu J, He M, Zhong X. Diagnosis and Treatment of Pythium Insidiosum Corneal Ulcer in a Chinese Child: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:982-988. [PMID: 28025573 PMCID: PMC5207016 DOI: 10.12659/ajcr.901158] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patient: Male, 7 Final Diagnosis: Pythium insidiosum Symptoms: Painful vision loss • red eye Medication:— Clinical Procedure: Application of multiple antifungal medicines followed by the penetrating keratoplasty Specialty: Ophthalmology
Collapse
Affiliation(s)
- Hong He
- Hainan Eye Hospital and Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, Hainan, China (mainland)
| | - Hongshan Liu
- Hainan Eye Hospital and Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, Hainan, China (mainland)
| | - Xiaolian Chen
- Hainan Eye Hospital and Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, Hainan, China (mainland)
| | - Jiaochan Wu
- Hainan Eye Hospital and Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, Hainan, China (mainland)
| | - Miao He
- Zhongshan Ophthalmic Center and State Key Laboratory of Ophthalmology, Sun Yat-sen Universityq, Guangzhou, Guangdong, China (mainland)
| | - Xingwu Zhong
- Hainan Eye Hospital and Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, Hainan, China (mainland).,Zhongshan Ophthalmic Center and State Key Laboratory of Ophthalmology, Sun Yat-sen Universityq, Guangzhou, Guangdong, China (mainland)
| |
Collapse
|
18
|
Lelievre L, Borderie V, Garcia-Hermoso D, Brignier AC, Sterkers M, Chaumeil C, Lortholary O, Lanternier F. Imported pythium insidiosum keratitis after a swim in Thailand by a contact lens-wearing traveler. Am J Trop Med Hyg 2014; 92:270-3. [PMID: 25535313 DOI: 10.4269/ajtmh.14-0380] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A 30-year-old woman with a history of contact lens wear and exposure to swimming pool water in Thailand presented with a non-responsive, progressive corneal ulcer of the right eye. Confocal microscopy evidenced septate linear branching structures, raising suspicion of fungal keratitis. She was promptly treated with topical antibiotics and both topical and intravenous caspofungin plus voriconazole. Worsening of the clinical picture after 1 month of intensive medical therapy led to a large therapeutic penetrating keratoplasty being performed. Corneal cultures grew a mold-like organism, which was identified by sequencing as Pythium insidiosum, an aquatic oomycete. After 4 years of follow-up, the graft exhibits no infection relapse, but graft transparency has been lost after two rejection episodes. Keratoplasty combined with antifungal treatment may offer a cure to P. insidiosum keratitis, although long-term preservation of corneal transparency is difficult to obtain.
Collapse
Affiliation(s)
- Lucie Lelievre
- Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, APHP, Paris, France; Fédération de Pathologie Infectieuse Oculaire, Centre de Recherche Institut de la Vision, UMR S 968 Inserm/UPMC/CHNO des Quinze-Vingts, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France; Service de Microbiologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France
| | - Vincent Borderie
- Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, APHP, Paris, France; Fédération de Pathologie Infectieuse Oculaire, Centre de Recherche Institut de la Vision, UMR S 968 Inserm/UPMC/CHNO des Quinze-Vingts, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France; Service de Microbiologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France
| | - Dea Garcia-Hermoso
- Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, APHP, Paris, France; Fédération de Pathologie Infectieuse Oculaire, Centre de Recherche Institut de la Vision, UMR S 968 Inserm/UPMC/CHNO des Quinze-Vingts, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France; Service de Microbiologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France
| | - Anne C Brignier
- Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, APHP, Paris, France; Fédération de Pathologie Infectieuse Oculaire, Centre de Recherche Institut de la Vision, UMR S 968 Inserm/UPMC/CHNO des Quinze-Vingts, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France; Service de Microbiologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France
| | - Margaret Sterkers
- Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, APHP, Paris, France; Fédération de Pathologie Infectieuse Oculaire, Centre de Recherche Institut de la Vision, UMR S 968 Inserm/UPMC/CHNO des Quinze-Vingts, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France; Service de Microbiologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France
| | - Christine Chaumeil
- Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, APHP, Paris, France; Fédération de Pathologie Infectieuse Oculaire, Centre de Recherche Institut de la Vision, UMR S 968 Inserm/UPMC/CHNO des Quinze-Vingts, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France; Service de Microbiologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France
| | - Olivier Lortholary
- Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, APHP, Paris, France; Fédération de Pathologie Infectieuse Oculaire, Centre de Recherche Institut de la Vision, UMR S 968 Inserm/UPMC/CHNO des Quinze-Vingts, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France; Service de Microbiologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France
| | - Fanny Lanternier
- Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, APHP, Paris, France; Fédération de Pathologie Infectieuse Oculaire, Centre de Recherche Institut de la Vision, UMR S 968 Inserm/UPMC/CHNO des Quinze-Vingts, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, Paris, France; Service de Microbiologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France
| |
Collapse
|