Corrigendum: Unraveling the dynamics of wheat leaf blight complex: isolation, characterization, and insights into pathogen population under Indian conditions

[This corrects the article DOI: 10.3389/fmicb.2024.1287721.].

Unraveling the dynamics of wheat leaf blight complex: isolation, characterization, and insights into pathogen population under Indian conditions

Wheat, a staple food crop for 35% of the global population, faces a threat from Helminthosporium leaf blight (HLB), a complex of spot blotch (Bipolaris sorokiniana) and tan spot (Pyrenophora-tritici-repentis) diseases under warm and humid conditions. However, in Indian conditions, the knowledge of existing pathogen populations associated with the HLB complex is limited and largely dominated by only B. sorokiniana (spot blotch). To address this, diseased samples were collected from all six wheat growing zones during 2020-2022. The pathogenic species were identified through in-depth morphological characterization, supplemented with ITS-rDNA and GAPDH sequence analysis, a diagnostic SCAR marker, and pathogenicity studies on two wheat varieties: Sonalika and HD2733. The 32 isolates collected from 10 different states consist of B. spicifera (12.5% of all isolates), Exserohilum rostratum (9.3%), Bipolaris oryzae (3.1%), and B. sorokiniana (75%). B. sorokiniana exhibited the highest disease severity on both varieties. Other lesser-known pathogenic species also produced comparable disease severity as B. sorokiniana isolates and, therefore are economically important. Unraveling pathogen composition and biology aids in disease control and resistance breeding. Our study highlights economically impactful and lesser-known pathogenic species causing wheat leaf blight/spot blotch in India, guiding both current management and future resistance breeding strategies in plant pathology.

italica) in China

Broccoli (Brassica oleracea var. italica) is not only an important crop worldwide with a large amount of production and consumption annually, but also rich in biologically active compounds (Surh et al., 2021). In November 2022, an unknown leaf blight was observed in the Broccoli planting area, Wenzhou City of Zhejiang Province (28.05 °N, 120.31 °E). Symptoms initially occurred at the leaf margin with yellow to gray lesions that were irregular and wilting. Approximately 10% of the surveyed plants were affected. To determine the pathogen, leaves with blight were collected randomly from five B. oleracea plants. Tissue blocks (3×3 mm) from diseased leaf portions were disinfected with 75% ethanol, rinsed three times with sterilized water, placed aseptically onto potato dextrose agar (PDA) medium, and incubated for 5 days at 28℃ in darkness. Seven fungal isolates with the same morphology were obtained using the spore method. The observed colonies were circular, taupe, pewter in color with light gray edging and many cottony aerial mycelia. Conidia were straight, curved or slightly bent, ellipsoidal to fusiform, and septate (typically 4-8 septa per conidium), with the size of 50.0-90.0 μm × 10.0-20.0 μm (n=30). The conidia had a slightly protruding and truncate hilum. These morphological characteristics were consistent with Exserohilum rostratum (Sharma et al., 2014). To further identify the pathogen, isolate WZU-XLH1 was chosen as a representative and the internal transcribed spacer (ITS) and glyceraldehyde-3-phosphate dehydrogenase-like (GAPDH) gene were amplified and sequenced using primer pairs ITS1/ITS4 (White et al., 1990) and Gpd1/Gpd2 (Berbee et al., 1999), respectively. The ITS and gpd gene sequences of isolate WZU-XLH1 were deposited in the GenBank database with accession numbers OQ750113 and OQ714500, respectively. BLASTn analysis showed matches of 568/571 (MH859108) and 547/547 (LT882549) with Exserohilum rostratum CBS 188.68. A neighbor-joining phylogenetic tree was constructed by combining the two sequenced loci, this isolate in the E. rostratum species complex clade at 71% bootstrap support.To verify the pathogenicity of the isolate, ten healthy Broccoli (cultivar 'You Xiu') seedlings with at least five leaves were divided into two groups: one group was inoculated with the isolate, while the other group served as a control. After surface disinfection with 75% ethanol and wiping with sterile water, tiny wounds were made on two leaves (two wounds in one leaf) using an inoculation needle. Fungal culture plugs cut from the isolate were placed on the wounds, while sterile PDA plugs served as the control. The leaves were sealed in wet airtight bags to retain moisture at room temperature with natural light (Cao et al., 2022). After five days, all leaves inoculated with isolate WZU-XLH1 showed symptoms identical to those observed in the field, with no symptoms present in the control group. The pathogenicity was confirmed by repeating the test in triplicate, and fungi re-isolated from symptomatic leaves were identified as E. rostratum by the morphological and molecular methods described above. To the best of our knowledge, this is the first report of E. rostratum causing leaf blight on broccoli in China. This study contributes to our understanding of B. oleracea leaf blight and establishes a basis for future studies on E. rostratum to develop management strategies.

First Report of Leaf Spot on Cherry Tomatoes Caused by Exserohilum rostratum in Hainan Province, China

Cherry tomatoes (Lycopersicon esculentum var. cerasiforme) is the main tomato variety planted in Hainan Province, China and is prized for its nutritional value and sweet taste (Zheng et al. 2020). During October 2020 to February 2021, a leaf spot disease was observed on cherry tomatoes (cultivar Qianxi) in Chengmai, Hainan Province. The disease incidence was approximately 40% in each of three fields in Yongfa (19°76'-21°08'N, 110°21'-110°51'E). Leaves were initially chlorotic before developing black, irregular-shaped lesions on the leaf margins or tips. After several days, lesions expanded along the mid-vein to encompass the entire leaf. Then, the affected leaves turned gray-brown, leading to defoliation. Severely affected leaves became dry and necrotic. Leaf tissues of 10 diseased plants samples collected from the fields were surface sterilized in 70% ethanol for 30 s, 0.1% HgCl2 for 30 s, rinsed thrice with sterile distilled water for 30 s, placed on a modified potato dextrose agar (PDA) with 30 mg/liter of kanamycin sulfate, and incubated at 28°C in the dark for 3 to 5 days. Three fungal isolates were obtained from the diseased leaves by single-sporing. The mycelia on PDA were white and later became gray or dark gray after 3 to 4 days. Conidia were rostrate, straight to slightly curved, ellipsoidal to narrowly obclavate, dark brown, protuberant with a darker and thicker wall at the basal end. Conidia were 4 to 12 distoseptate and measured 63.92 ± 5.77 × 13.47 ± 1.22 µm (n= 50) Conidiophores were single, cylindrical, dark brown, geniculate, with swollen conidiogenous cells containing a acircular conidial scar. Morphological characteristics of the isolates were similar to those of Exserohilum rostratum (Cardona et al. 2008). A representative isolate (FQY-7) was used for pathogenicity and genomic studies. Genomic DNA was extracted from the mycelium of a representative isolate (FQY-7). The internal transcribed spacer (ITS) region, actin (act), translation elongation factor 1-alpha (tef1-α), glyceraldehydes 3-phos-phate dehydrogenase (gapdh) and β-tubulin (tub2) genes were amplified with primers ITS1/ITS4 (White et al. 1990), Act1/Act4 (Voigt and Wöstemeyer 2000), EF1-728F/EF1-986R (Carbone and Kohn 1999), Gpd-1/Gpd-2 (Berbee et al. 1999) and T1 (O'Donnell and Cigelnik 1997) + Bt2b (Glass and Donaldson 1995). The consensus sequences (GenBank Accession No. MW036279 for ITS, MW133266 for act, MW133268 for tef1-α, MW133267 for gapdh, and MW133269 for tub2) were aligned using BLAST in GenBank obtaining 100%, 100%, 99%, 100%, and 99% identity to E. rostratum strain CBS706 (LT837842, LT837674, LT896663, LT882546, LT899350). Maximum likelihood analysis based on the combined five gene sequences was conducted under 1,000 bootstrap replicates. The Phylogenetic tree showed that FQY-7 and E. rostratum were located in one clade supported with 99% bootstrap values. Pathogenicity test was performed by depositing 10-µl droplets of a conidial suspension (1 × 106 per ml) into 5 noninoculated leaves (using a sterile needle) of 10 healthy 5-month-old cherry tomato (cv. Qianxi) plants. An equal number of artificially control leaves were received only sterile water to serve as a negative control. The test was conducted three times. Plants were kept at 28°C with 80% humidity and observed for symptoms every day. Two weeks after inoculation, all the inoculated plants showed symptoms of black spots similar to those observed in the field. No symptoms were observed on the controls. FQY-7 was successfully re-isolated from the inoculated leaves and confirmed by morphological characterization and molecular assays as described herein. To the best of our knowledge, this is the first report of leaf spot of cherry tomatoes caused by E. rostratum in China. Confirming the existence of this pathogen in this area will be useful to adopt effective field management measures to control this disease on cherry tomatoes. References: Berbee, M. L., et al. 1999. Mycologia 91:964. Cardona, R. et al. 2008. Bioagro 20:141. Carbone, I. and Kohn, L. M. 1999. Mycologia 91:553. Glass, N. L., and Donaldson, G. C. 1995. Appl. Environl. Microb. 61:1323. White, T. J., et al. 1990. Page 315 in: PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, CA. O'Donnell K., and Cigelnik, E. 1997. Mol. Phylogenet. Evol. 7:103. Voigt, K., and Wöstemeyer, J. 2000. Microbiol. Res. J. 155:179. Zheng J., et al. 2020. Guangdong Agr. Sci. 47:212. The author(s) declare no conflict of interest.

The Chromosome-Scale Genomes of Exserohilum rostratum and Bipolaris zeicola Pathogenic Fungi Causing Rice Spikelet Rot Disease

Rice spikelet rot disease occurs mainly in the late stages of rice growth. Pathogenicity and biological characteristics of the pathogenic fungus and the infestation site have been the primary focus of research on the disease. To learn more about the disease, we performed whole-genome sequencing of Exserohilum rostratum and Bipolaris zeicola for predicting potentially pathogenic genes. The fungus B. zeicola was only recently identified in rice.We obtained 16 and 15 scaffolds down to the chromosome level for E. rostratum LWI and B. zeicola LWII, respectively. The length of LWI strain was approximately 34.05 Mb, and the G + C content of the whole genome was 50.56%. The length of the LWII strain was approximately 32.21 Mb, and the G + C content of the whole genome was 50.66%. After the prediction and annotation of E. rostratum LWI and B. zeicola LWII, we predicted that the LWI strain and LWII strain contain 8 and 13 potential pathogenic genes, respectively, which may be related to rice infection. These results improve our understanding of the genomes of E. rostratum and B. zeicola and update the genomic databases of these two species. It benefits subsequent studies on the mechanisms of E. rostratum and B. zeicola interactions with rice and helps to develop efficient control measures against rice spikelet rot disease.

Co-Inoculation of an Endophytic and Arbuscular Mycorrhizal Fungus Improve Growth and Yield of Helianthus tuberosus L. under Field Condition

Endophytic fungi (EPF) and arbuscular mycorrhizal fungi (AMF) symbioses can promote the growth and productivity of several types of plants. This work aimed to investigate the effect of co-inoculation of an EPF Exserohilum rostratum NMS1.5 and an AMF Glomus etunicatum UDCN52867 g.5 on the growth and yields of sunchoke (Helianthus tuberosus L.) compared to the effects of full-dose and half-dose chemical fertilizer (15-15-15) under field conditions. Several plant growth parameters of the co-inoculated plants were significantly higher than the other treatments. Remarkably, such an effect was relatively equal to that of the full-dose chemical fertilizers. Moreover, the co-inoculation of EPF and AMF significantly improved the tuber yield production, even better than the use of a chemical fertilizer. This is the first report to show that plant growth promoting effects of the co-inoculation of EPF and AMF were exceptionally greater than those of the chemical fertilizer. Therefore, our EPF and AMF could potentially be used as a biofertilizer for promoting the growth and yield of sunchoke in the fields.

Assessing Genetic Resistance in Wheat to Black Point Caused by Six Fungal Species in the Yellow and Huai Wheat Area of China

The most effective and environmentally sustainable method for controlling black point disease of wheat (Triticum aestivum L.) is to plant resistant cultivars. To identify sources of resistance to black point, 165 selected cultivars/lines were inoculated with isolates of six fungal species (Bipolaris sorokiniana, Alternaria alternata, Fusarium equiseti, Exserohilum rostratum, Epicoccum sorghinum, and Curvularia spicifera) known to cause black point in wheat using spore suspensions under controlled field conditions in 2016 and 2017. Inoculation of the isolates significantly increased the incidence of black point in the cultivars/lines compared with those grown under natural field conditions (NFC). The disease incidence of plants inoculated with B. sorokiniana and E. rostratum was 15.5% and 18.8% in 2016, and 20.4% and 23.0% in 2017, whereas those under NFC were 5.7% (2016) and 1.5% (2017), respectively. Furthermore, disease symptoms varied with pathogen. Among the 165 cultivars/lines tested, 3.6%, 50.9%, 60.0%, 1.8%, 47.3%, and 58.8% were resistant to B. sorokiniana, A. alternata, F. equiseti, E. rostratum, E. sorghinum, and C. spicifera, respectively. In addition, we identified one line ('SN530070') resistant to black point caused by all six pathogens. This is the first study to assess resistance to wheat black point caused by six fungal species under controlled conditions. The black point-resistant cultivars/lines could be useful in breeding and also in research on the mechanisms of resistance to black point.

Long-term Outcomes of Patients With Fungal Infections Associated With Contaminated Methylprednisolone Injections

Background

The largest health care–associated infection outbreak in the United States occurred during 2012–2013. Following injection of contaminated methylprednisolone, 753 patients developed infection with a dematiaceous mold, Exserohilum rostratum. The long-term outcomes of these infections have not been described.

Methods

This retrospective cohort study of 440 of a total of 753 patients with proven or probable Exserohilum infection evaluated clinical and radiographic findings, antifungal therapy and associated adverse effects, and outcomes at 6 weeks, 3, 6, 9, and 12 months after diagnosis. Patients were grouped into 4 disease categories: meningitis with/without stroke, spinal or paraspinal infections, meningitis/stroke plus spinal/paraspinal infections, and osteoarticular infections.

Results

Among the 440 patients, 223 (51%) had spinal/paraspinal infection, 82 (19%) meningitis/stroke, 123 (28%) both, and 12 (3%) osteoarticular infection. Of 82 patients with meningitis/stroke, 18 (22%) died; among those surviving, 87% were cured at 12 months. Only 7 (3%) of 223 patients with spinal/paraspinal infection died, but at 12 months, 68% had persistent or worsening pain and only 47% were cured. For the 123 patients with both meningitis/stroke and spinal/paraspinal infection, 10 (8%) died, pain persisted in 72%, and 52% were cured at 12 months. Only 37% of those with osteoarticular infection were cured at 12 months. Adverse events from antifungal therapy were noted at 6 weeks in 71% of patients on voriconazole and 81% on amphotericin B.

Conclusions

Fungal infections related to contaminated methylprednisolone injections culminated in death in 8% of patients. Persistent pain and disability were seen at 12 months in most patients with spinal/paraspinal infections.

Efficacy of Cerebrospinal Fluid Beta-d-Glucan Diagnostic Testing for Fungal Meningitis: a Systematic Review

Several case reports and cohort studies have examined the use of (1,3)-beta-d-glucan measurement with cerebrospinal fluid to diagnose fungal meningitis. This systematic review aims to characterize the evidence regarding cerebrospinal fluid (1,3)-beta-d-glucan measurement to detect fungal meningitis. We searched PubMed for (1,3)-beta-d-glucan and each of several distinct fungi, cerebrospinal fluid, and meningitis. Summary data including diagnostic performance (where applicable) were recorded. A total of 939 records were examined via a PubMed search. One hundred eighteen records remained after duplicates were removed, and 104 records were excluded, as they did not examine cerebrospinal fluid, included animals, or focused on nonfungal infections. Fourteen studies were included in this systematic review. A variety of fungi, including species of Candida, Aspergillus, Exserohilum, Cryptococcus, Histoplasma, and Coccidioides, were studied, although most were case reports. Diagnostic accuracy was examined in 5 studies. Cerebrospinal fluid (CSF) (1,3)-beta-d-glucan measurement showed >95% sensitivity in the corticosteroid injection-related outbreak of Exserohilum rostratum One study in Histoplasma meningitis found 53% (53/87) sensitivity and 87% (133/153) specificity, while another study of Cryptococcus meningitis found 89% (69/78) sensitivity and 85% (33/39) specificity. CSF (1,3)-beta-d-glucan testing may be useful, primarily as a nonspecific marker of fungal meningitis. Although the FDA black box warning states that Cryptococcus spp. do not make (1,3)-beta-d-glucan, the current evidence shows that (1,3)-beta-d-glucan is detectable in cryptococcal meningitis. Organism-specific testing should be used in conjunction with (1,3)-beta-d-glucan measurement.

[Phaeohyphomycosis by Exserohilum rostratum in a pediatric patient with acute lymphoblastic leukemia after bone marrow transplantation]

The genus Exserohilum consists of dematiaceous or darkly pigmented fungi. Most of the species included in this genus are phytopathogens, saprobes and only three of these species would be pathogenic to humans: Exserohilumrostratum, Exserohilumlongirostratum and Exserohilummcginnisii. Localized and systemic infections have been reported both in immunocompetent and immunosuppressed patients. A clinical case of cutaneous infection by E. rostratum in an immunocompromised pediatric patient is presented in this study.'

Exserohilum rostratum Keratitis in a Patient with Human Immunodeficiency Virus

Purpose

To report a case of fungal keratitis infected by Exserohilum rostratumin a human immunodeficiency virus (HIV) patient.

Method

A retrospective study of the HIV patient with keratomycosis caused by E. rostratumwas reviewed for history, clinical characteristics, risk factors, laboratory findings, treatments, and outcomes.

Results

A 48-year-old man with HIV infection presented with a history of trauma with an unknown species of insect in the right eye. He also had redness and blurred vision in the right eye. Biomicroscopic examination showed white infiltrate in the right cornea. A feathery edge, satellite lesion, and brownish pigmented deposits in the epithelial surface and anterior stroma were noted. Corneal scraping specimen showed numerous large dematiaceous septate hyphae and polymerase chain reaction (PCR) identified E. rostratum.Treatment was started with 5% natamycin eyedrops and oral itraconazole. The corneal lesion responded well to medication and debridement.

Conclusions

Corneal phaeohyphomycosis caused by Exserohilumwas noted in an immunocompromised patient with ocular trauma. A brown pigmented lesion in an otherwise white infiltrate due to Exserohilumwas diagnosed with corneal scrapings and polymerase chain reaction. Antifungal medications and debridement were the mainstay of corneal fungal infection treatment.

Allergic Fungal Sinusitis Caused by Exserohilum rostratum and Literature Review

A case of allergic fungal sinusitis (AFS) caused by Exserohilum rostratum, proven by culture and histopathology of the biopsy material, is described. The identity of the isolate was confirmed by sequencing of ITS region of rDNA. To the best of our knowledge, this is the first report of allergic E. rostratum sinusitis from Kuwait and Arabian Peninsula. Ten previously described cases of AFS have been reviewed. The report highlights the emerging importance of E. rostratum as a human pathogen in this region and role of molecular methods in its accurate identification.

[Invasive acute sinusitis by Exserohilum rostratum in a patient with medullary relapse of acute lymphoblastic leukemia]

Invasive fungal infection has increased in frequency over the last decade, with fungal sinusitis becoming more frequent. The fungi of the genus Exserohilum (family Pleosporaceae, order Pleosporales) are filamentous and dematiaceous of ubiquitous location. It is an emerging pathogen, which in most cases produces a systemic infection that mainly affects the paranasal sinuses and lungs. It is more common in immunosuppressed patients, although it may occur in immunocompetent patients. The treatment is based on three pillars: antifungal treatment, surgical debridement and restitution of immunity. We present the case of a patient with medullary relapse of acute lymphoblastic leukemia with invasive fungal sinusitis by Exserohilum rostratum.

Healthcare-associated fungal outbreaks: New and uncommon species, New molecular tools for investigation and prevention

Outbreaks of healthcare-associated fungal infections have repeatedly been described over recent years, often caused by new or uncommon species. Candida auris, a recently described multidrug-resistant yeast species, is certainly the most worrisome species having caused several severe healthcare outbreaks of invasive infections, on four continents. Also, large nosocomial outbreaks due to uncommon fungal species such as Exserohilum rostratum and Sarocladium kiliense, were both linked to contamination of medical products, however the source of another outbreak, caused by Saprochaete clavata, remains unresolved. Furthermore, these outbreaks identified new populations under threat in addition to those commonly at risk for invasive fungal infections, such as immunosuppressed and intensive care unit patients. All of these outbreaks have highlighted the usefulness of a high level of awareness, rapid diagnostic methods, and new molecular typing tools such as Whole Genome Sequencing (WGS), prompt investigation and aggressive interventions, including notification of public health agencies. This review summarizes the epidemiological and clinical data of the majority of healthcare-associated outbreaks reported over the last 6 years caused by uncommon or new fungal pathogens, as well as the contribution of WGS as support to investigate the source of infection and the most frequent control measures used.

Sinusitis caused by Exserohilum rostratum after cord blood transplantation for myelodysplastic syndrome: A case report and literature review

Invasive fungal disease is a serious infectious complication of allogeneic hematopoietic stem cell transplantation (HSCT). Exserohilum rostratum is a species causing phaeohyphomycosis, which rarely causes invasive disease in humans. We treated a case of sinusitis caused by E. rostratum after cord blood transplantation (CBT). A 60-year-old man with myelodysplastic syndrome, who had a medical history of an operation to correct deviation of the nasal septum, developed sinusitis caused by E. rostratum under prolonged profound neutropenia after a second CBT because of the graft rejection of the first transplantation. Liposomal amphotericin B improved the sinusitis. A literature review revealed nine reported cases of sinusitis caused by E. rostratum, including our case. Although five cases had severe neutropenia at onset (HSCT recipients, n = 2; aplastic anemia, n = 3), the remaining four had no preexisting immunosuppressive conditions. However, three of the four patients had preexisting nasal diseases with or without a history of surgery, as in our case. Excluding our case, the outcome was fatal in five neutropenic patients, whereas the four patients without neutropenia recovered. Although sinusitis caused by E. rostratum is rare, E. rostratum should be recognized as a possible pathogen causing sinusitis in highly immunosuppressed patients such as HSCT recipients. Preexisting nasal disease and/or nasal surgery could be risks for this infection.

Molecular diagnosis of invasive mycoses of the central nervous system

INTRODUCTION

In September 2012, the Centers for Disease Control and Prevention (CDC) began investigating an outbreak of fungal meningitis among patients who had received contaminated preservative-free methyl prednisolone acetate injections from the New England Compounding Center in Framingham, Massachusetts. Thousands of patients were potentially exposed to tainted corticosteroids, but establishing the diagnosis of fungal meningitis during the nationwide outbreak was difficult because little was known about the natural history of the disease. Areas covered: The challenges associated with this outbreak highlighted the need for rapid and reliable methodologies to assist in the diagnosis of invasive mycoses of the central nervous system (IMCNS), which may be devastating and difficult to treat. In this paper, we review the causative agents of these potentially-lethal infections, which include cryptococcal meningitis, cerebral aspergillosis, and hematogenous Candida meningoencephalitis. Expert commentary: While microscopy, culture, and histopathologic identification of fungal pathogens remain the gold standard for diagnosis, new platforms and species-specific assays have recently emerged, including lateral flow immunoassays (LFA), matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), and multiplex PCR in conjunction with magnetic resonance (MR) to potentially aid in the diagnosis of IMCNS.

Methylprednisolone impairs conidial phagocytosis but does not attenuate hyphal damage by neutrophils against Exserohilum rostratum

Exserohilum rostratum caused a multistate fungal meningitis outbreak following iatrogenic inoculation of contaminated methylprednisolone in the United States. To gain insight into the immunopathogenesis of this infection, we studied the innate host responses of human neutrophils against E. rostratum conidia and hyphae with or without methylprednisolone. The neutrophil-induced percentage fungal damage against conidia and hyphae was effector-to-target ratio dependent (≤55%). While methylprednisolone did not affect neutrophil-induced fungal damage by treatment of Exserohilum or neutrophils, it compromised phagocytosis of conidia (P < 0.05). These findings suggest that methylprednisolone-treated neutrophils may have altered phagocytic clearance of Exserohilum conidia, reducing host capacity to contain the invasive process.

Methylprednisolone enhances the growth of Exserohilum rostratum in vitro, attenuates spontaneous apoptosis, and increases mortality rates in immunocompetent Drosophila flies

High concentrations of methylprednisolone (0.32 mg/mL) accelerated growth and attenuated spontaneous apoptosis of Exserohilum rostratum in vitro. Injection of E. rostratum conidia preexposed to 0.32 mg/mL of methylprednisolone for 7 days in immunocompetent flies led to increased mortality and a higher fungal burden. Exposure to methylprednisolone could enhance the virulence of E. rostratum.

Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections

BACKGROUND

A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone.

METHODS

Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports.

RESULTS

Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection.

CONCLUSIONS

We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.

What can we learn and what do we need to know amidst the iatrogenic outbreak of Exserohilum rostratum meningitis?

The tragedy of the ongoing epidemic of meningitis caused by Exserohilum rostratum brings into focus the epidemiology, risk factors, pathogenesis, diagnosis, and treatment of a multitude of opportunistic mold infections of the central nervous system. Herein we provide our perspective regarding the translational research objectives of this infection that are needed to make an impact on this important healthcare crisis.

Hospital-acquired phaeohyphomycosis due to Exserohilum rostratum in a child with leukemia

The present study describes a case of cutaneous phaeohyphomycosis caused by Exserohilum rostratum in a child undergoing treatment for leukemia. The infection was possibly due to contaminated intravenous dressings and was successfully treated with surgical excision combined with liposomal amphotericin B. Consequently, new infection control policies have been implemented at CHU Sainte-Justine (Montreal, Quebec).