Clonal Dissemination of Candida auris Clinical Isolates in Northern Italy, 2021

Candida auris is a concerning pathogen in health care due to its ability to spread in medical settings. In this study, we characterized the genome of three C. auris clinical isolates collected in the Emilia-Romagna region of Northeastern Italy from January 2020 to May 2021. Whole-genome sequencing was performed using Illumina iSeq 100 and Oxford Nanopore MinION systems. Genomes were assembled with Flye. Phylogenetic analysis was carried out with RaxML. The ERG11, TAC1b, and FKS1 genes were examined for known substitutions associated with resistance to azoles and caspofungin using Diamond. All three C. auris isolates belonged to clade I (South Asian lineage) and showed high minimum inhibitory concentrations for fluconazole. Two of the three isolates were closely related to the first Italian index case of C. auris occurred in the 2019 and carried similar mutations associated to azole resistance. The third isolate showed a greater phylogenetic distance from these strains and had a different genetic determinant not previously seen in Italy. Our data suggest that two C. auris clinical isolates may have been epidemiologically related to the first outbreak previously observed in Italy, while the remaining isolate may have originated from a different source. Further research is needed to understand C. auris transmission and resistance and to control its spread.

Potential use of artificial intelligence for vaginal swab analysis in the assessment of common genital disorders: a pilot study

Genital disorders, such as vulvo-vaginal candidiasis (VVC), bacterial vaginosis (BV), and aerobic vaginitis (AV), are very common among fertile women and negatively impact their reproductive and relational life. Vaginal culture can help in the diagnostic workflow of these conditions. Recently, culture-based techniques have taken advantages of up-front specimen processing units, which also include a digital imaging system to record images of plates at programmable time points. In this proof-of-concept study, we assessed the characteristics of digital plate images of vaginal swabs plated by WASPLab system into different media, in order to detect microbial growth morphotypes specific for each genital disorder. A total of 104 vaginal specimens were included: 62 cases of normal lactobacilli-dominated flora, 12 of BV, 16 of VVC, and 14 of AV were analysed. Vaginal specimens were plated by WASPLab system into different chromogenic media and blood agar plates. Plate images were taken automatically by the digital imager at 38 h post-inoculation. We found that each genital condition was characterized by specific morphotypes in terms of microbial growth and colony colour, thus allowing the potential use of artificial intelligence not only to assess the presence of specific microbial genera/species but also to 'categorize' peculiar clinical conditions.

Pseudozyma aphidis bloodstream infection in a patient with aggressive lymphoma and a history of intravenous drug use: Case report and review of the literature

Pseudozyma aphidis is an environmental fungus which causes opportunistic infections in immunocompromised patients. Here we report the case of a 54-year-old, intravenous drug user woman, newly diagnosed to have an aggressive lymphoma, who developed a bloodstream infection caused by P. aphidis treated successfully with amphotericin-B therapy. The precise identification was assessed by sequencing. We propose to consider intravenous drug use as a risk factor for invasive infections due to this environmental yeast.

Respiratory bacterial co-infections in intensive care unit-hospitalized COVID-19 patients: Conventional culture vs BioFire FilmArray pneumonia Plus panel

The prevalence and microbiology of concomitant respiratory bacterial infections in patients with SARS-CoV-2 infection are not yet fully understood. In this retrospective study, we assessed respiratory bacterial co-infections in lower respiratory tract samples taken from intensive care unit-hospitalized COVID-19 patients, by comparing the conventional culture approach to an innovative molecular diagnostic technology.

A total of 230 lower respiratory tract samples (i.e., bronchial aspirates or bronchoalveolar lavages) were taken from 178 critically ill COVID-19 patients. Each sample was processed by a semi-quantitative culture and by a multiplex PCR panel (FilmArray Pneumonia Plus panel), allowing rapid detection of a wide range of clinically relevant pathogens and a limited number of antimicrobial resistance markers.

More than 30% of samples showed a positive bacterial culture, with Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus the most detected pathogens.

FilmArray showed an overall sensitivity and specificity of 89.6% and 98.3%, respectively, with a negative predictive value of 99.7%. The molecular test significantly reduced the turn-around-time (TAT) and increased the rates of microbial detection. Most cases missed by culture were characterized by low bacterial loads (10⁴–10⁵ copies/mL). FilmArray missed a list of pathogens not included in the molecular panel, especially Stenotrophomonas maltophilia (8 cases).

FilmArray can be useful to detect bacterial pathogens in lower respiratory tract specimens of COVID-19 patients, with a significant decrease of TAT. The test is particularly useful to rule out bacterial co-infections and avoid the inappropriate prescription of antibiotics.

Metabolic profiling of Candida clinical isolates of different species and infection sources

Candida species are the most common cause of opportunistic fungal infections. Rapid identification and novel approaches for the characterization of these fungi are of great interest to improve the diagnosis and the knowledge about their pathogenic properties. This study aimed to characterize clinical isolates of Candida spp. by proteomics (MALDI-TOF MS) and metabolomics (1H-NMR), and to correlate their metabolic profiles with Candida species, source of infection and different virulence associated parameters. In particular, 49 Candida strains from different sources (blood, n = 15; vagina, n = 18; respiratory tract, n = 16), belonging mainly to C. albicans complex (61%), C. glabrata (20%) and C. parapsilosis (12%) species were used. Several extracellular and intracellular metabolites showed significantly different concentrations among isolates recovered from different sources of infection, as well as among different Candida species. These metabolites were mainly related to the glycolysis or gluconeogenesis, tricarboxylic acid cycle, nucleic acid synthesis and amino acid and lipid metabolism. Moreover, we found specific metabolic fingerprints associated with the ability to form biofilm, the antifungal resistance (i.e. caspofungin and fluconazole) and the production of secreted aspartyl proteinase. In conclusion, 1H-NMR-based metabolomics can be useful to deepen Candida spp. virulence and pathogenicity properties.

Occurrence of Albifimbria verrucaria in the Blood of a Female Child With Neuroblastoma

We report for the first time the occurrence of a filamentous fungus, Albifimbria verrucaria, in the blood of a pediatric neuroblastoma patient. The Albifimbria genus comprises common soil-inhabiting and saprophytic fungi and has been isolated as a plant pathogen in Northern and Southern Italy. As a human pathogen, A. verrucaria has been implicated in keratitis and can produce trichothecene toxins, which are weakly cytotoxic for mammalian cell lines. A. verrucaria was isolated from blood during the follow-up of a previous coagulase-negative Staphylococcus catheter-related infection. Lung nodules, compatible with fungal infection, had been observed on a CT scan 6 months earlier; they still persist. Possible routes of transmission were considered to be airborne, catheter related, or transfusion dependent, as the patient had undergone platelet and red blood cell transfusions during rescue chemotherapy. No filamentous fungi were isolated from sputum or CVCs. In conclusion, we describe an unprecedented fungemia caused by A. verrucaria and show how an unexpected pathogen may be acquired from the environment by patients at high risk due to immunosuppression. The route of transmission remains unknown.

Critical analysis of aortic dysmorphism in Marfan Syndrome

Introduction: Marfan syndrome (OMIM #154700) was described for the first time in 1896 by Antoine Bernard-Jean Marfan. It is characterized by its autosomal dominant inheritance pattern, affects 1:5000 of those born alive, and involves the gene that codifies the structural protein fribrillin-1. Fibrillin-1 is critical for the formation of the elastic system backbone and for the negative regulation of the cytokine transforming growth factor beta 1 (TGF-β1). In the syndrome this fibrillar component causes the degeneration of the fibers of the elastic system, which no longer sequesters matrix TGF-β, causing disorganization of the collagen fibers and vascular smooth muscles. The disease affects mainly the cardiovascular system, cardiovascular problems being the main cause of death. This is because arteries have large amounts of elastic fibers that rupture in an adverse process, causing mainly dissections and aneurisms, which have been better clariied in experimental studies with mice. Objective: The objective of this study was to conduct an etiopathogenic and molecular review to describe the advances in the understanding of blood vessel dysmorphism in the syndrome, especially of the aorta. Materials and Methods: For this purpose the literature of the last 35 years was extensively reviewed. Conclusion: The origin of the aortic dysmorphism in the syndrome stems from a number of events that begin with the mutation of the gene fibrillin-1, causing fragmentation of the aortic elastic fibers. Excess cytokine TGF-β increases the amount of metalloproteinases and of vascular smooth muscle cell apoptosis, leading to matrix remodeling and increasing the susceptibility of the vessel to an aneurysm or dissecting process.

Reparation of a severe case of aplasia cutis congenita with engineered skin

Aplasia cutis congenita (ACC) is an uncommon congenital malformation. It is characterized by defects of the skin that occur most frequently on the scalp along the midline, but can also be localized on the trunk, face and limbs, usually with a symmetrical distribution. When it is localized in the skull it can extend to the dura mater, leaving only the thin pia mater to protect the brain. The most common complications related to this disorder are infection, hemorrhage, and, in defects localized on the vertex, meningitis and bleeding from the sagittal sinus can occur with dramatic consequences. In those cases some authors suggest the use of local flaps even if this implies a surgical procedure. In this case a 2.540-kg baby was delivered at 40 weeks of gestation by eutocic delivery, and good adaptation to extrauterine life. At birth the baby showed a large cutaneous and osseous defect at the vertex measuring 68 cm(2), equal to almost one third of the calvarial surface, and extended to the dura mater through which it was possible to see the sagittal sinus and the brain surface with its vessels. Skull X-rays showed loss of normal radioopacity of the cranial vault with lack of ossification especially at the parietal level. In our patient we therefore decided to use a composite graft of cultured autologous fibroblasts and keratinocytes to provide coverage, avoiding any surgical procedure and patient morbidity. This technique consists first in an autograft of cultured fibroblasts which has proved to promote the production of type IV collagen, fibronectin and laminin whereby creating an ideal bed for the taking of the graft of cultured keratinocytes, to be put in place a week later. The use of a composite graft with both the derma-like and epithelial components has been also suggested to diminish scarring. Two months after the last graft area was completely closed.

A case of non-immune hydrops fetalis with congenital cystic adenomatoid malformation of the left lung in a twin

Hydrops fetalis is a rare condition that occurs in one out of every 1,400-4,000 pregnancies. There are two types, immune and non-immune. It can be caused by a maternal-fetal incompatibility due to the Rh factor or, more rarely, the Kell factor or due to other antigens to red corpuscles. Non-immune types of hydrops have a complex multiform pathogenesis and in 50% of the cases they are of idiopathic nature. The causes that could determine non-immune hydrops are manifold and in 50% of the cases they are of an idiopathic nature. Independently of the clinical condition, the presented case could be classified in those forms of pathogenesis in which there is the presence of a congenital cystic adenomatoid malformation (CAM), not encountered in the fetal ultrasound performed at the sixteenth week of pregnancy. The particularity of our case is due to the association of the fetal hydrops of the CAM type in only one of the two twins. The presented case is classified in those forms of hydrops that are expressed with a clinical trend towards a worse prognosis, characterized by the intrauterine death of the fetus or the birth of a hydropic fetus that does not survive because of respiratory insufficiency and cardiocirculatory collapse.

[Echography of the hip in premature infants]

The authors report the data relative to 50 preterm infants with gestational age less than or equal to 34 weeks. The newborns were studied sequentially with clinical and US examination from February 28, 1989 to March 23, 1990 in order to exclude hip dysplasia or dislocation. US examination was carried out according to Graf's technique. All the newborns had another clinical examination at one year of age in order to evaluate their normal walking. Risk factors had poor significance in the studied group of infants.

[Surfactant and ambroxol in the therapy of idiopathic respiratory syndrome in newborn infants]

The Authors have carried out a study on 30 newborns, affected by idiopathic respiratory distress syndrome (IRDS), divided into 3 statistically comparable groups, treated, in addition to mechanical ventilation, respectively with Tokio-Akita (TA) surfactant, placebo (both by endotracheal administration) and ambroxol given by intravenous infusion. The clinical evolution of the three groups was studied, above all as related to mortality, ventilation length, oxygen need, immediate and successive pulmonary complications and cerebral haemorrhage. Mortality was lower in the group treated with ambroxol, while the ventilation length, the average insufflation pressure and the oxygen need were lower in the group treated with surfactant, compared with the other two groups. Pulmonary complications were present only in the group treated with placebo and ambroxol, whereas cerebral haemorrhage rate is higher in the group treated with surfactant. On the basis of the results achieved, some important observations are suggested and possible aetiological therapies of IRDS are formulated.

[Pulmonary edema. A rare complication of the percutaneous insertion of silastic central venous catheters]

Seven newborn infants (birth weight 920 to 1,900 g) who developed pulmonary oedema as a complication of the use of percutaneous silastic central venous catheters are described. Clinical symptoms occurred three to forty days after catheter placement. In each case, radiographic detection, performed by the injection of radiopaque dye, localized the tip of the catheter in the pulmonary artery or in its collateral branches. Clinical symptoms decreased after catheter replacement in the right atrium. The casistic examination allows the Authors to suggest some aetiopathogenetic hypothesis.

[Percutaneous silicone catheters in the newborn infant]

246 percutaneous insertions of silastic venous catheters were performed in 189 newborn infants. This technique makes perfusion in newborn easier and safer, with less complication risks and less work for nurses. Furthermore silastic venous catheters insure a better observation of neonatological care methods. As a consequence it improves the vital prognosis and the quality of newborn survival in the newborn intensive care unit.