A prospective comparison of galactomannan in bronchoalveolar lavage fluid for the diagnosis of pulmonary invasive aspergillosis in medical patients under intensive care: comparison with the diagnostic performance of galactomannan and of (1→ 3)-ß-d-glucan chromogenic assay in serum samples.

Diagnosis of fungal pneumonia (FP) in critically ill patients is challenging. Circulating biomarkers for the diagnosis of FP have limitations and the combination of different assays in serum samples and directly from the target organ may further improve the diagnosis of FP. We prospectively assessed the diagnostic utility of paired galactomannan (GM) in bronchoalveolar lavage fluid (BAL) and serum GM and (1→3)-ß-D-glucan (BG) assays in critically ill patients at risk of FP. Patients with FP were classified according to European Organisation for Research and Treatment of Cancer-Mycoses Study Group criteria, with modifications. Out of 847 admissions, 51 patients were eligible. There were nine invasive aspergillosis (IA) cases (four proven, five probable), three proven Pneumocysitis jirovecii pneumonia (PJP) cases and one mixed FP case (probable IA and proven PJP). The diagnostic accuracy as given by the area under the receiver operating characteristic curve in IA cases (proven and probable) for GM in BAL was 0.98 (95% CI, 0.94-1.00), whilst for GM and BG in serum it was 0.85 (95% CI, 0.74-0.96) and 0.815 (95% CI, 0.66-0.96), respectively. For IA cases (proven and probable) AUC for GM in BAL was significantly higher than GM and BG in serum (p 0.025 and p 0.032, respectively). In one of four proven and one of six probable IA cases, GM in serum remained negative, whereas GM in BAL was positive. In patients with IA, GM (90%) and BG (80%) appeared a mean of 4.3 days (range, 1-10 days) before Aspergillus was cultured. GM detection in BAL appears to improve the diagnosis of IA in critical patients.

Clinical significance of the detection of Candida albicans germ tube-specific antibodies in critically ill patients.

The present study, comprising a prospective multicentre study including 53 non-neutropenic patients from intensive care units (ICU) in six Spanish tertiary-care hospitals, was carried out to determine the clinical significance and influence on mortality of Candida albicans germ tube-specific antibodies (CAGTA). There were 22 patients (41.5%) for whom the CAGTA results were positive, although none of had a blood culture positive for Candida. The intra-ICU mortality rate was significantly lower (p = 0.004) in CAGTA-positive patients (61.2% vs. 22.7%). Multivariate analysis confirmed that a positive CAGTA result was the only protective factor to be independently associated with ICU mortality (beta coefficient = -0.3856; 95% confidence interval = -0.648 to -0.123).

Randomized prospective comparative study: short-term treatment with ciclopiroxolamine (cream and solution) versus boric acid in the treatment of otomycosis.

Sixty-four patients with symptomatic otomycosis (80 infected ears) confirmed by direct microscopy and culture were randomly treated for I week with ciclopiroxolamine cream 11% (group A, 20 infected ears, 17 patients), ciclopiroxolamine solution 1% (group B, 20 infected ears, 17 patients) and boric acid (group C, 40 infected ears, 30 patients) and daily mechanical suction aspiration of the debris. An attempt was made to match 11 clinical parameters with both the mycological and bacteriological findings. There was no significant association between the fungal species cultured and the clinical parameters did not vary with the presence or absence of different bacteria; pus was never present in fungal otitis externa (Fisher's test, P < 0.001). Before therapy, a significant number of ears had completely sterile bacterial cultures (p < 0.01, chi2 test); saprophytic Gram-positive bacteria increased after treatment, whilst Gram-negative bacteria, Pseudomonas aeruginosa and Proteus species, decreased after treatment. Clinical total cure rates 3 days after the end of therapy ranged from 50% in group A, 25% in group B to 22.5% in group C. Mycological cure rates were 80% (group A), 95% (group B) and 72.5% (group C). Two weeks after the end of therapy the clinical cure rates were 60% (group A), 65% (group B) and 80% (group C) and the mycological cure rates was 65% for group A and 75% for both group B and C. Eleven patients relapsed with otitis externa: four (20%) in groups A and C and three (15%) in group B. In four cases the infection was due to bacteria and the remaining seven were due to fungi. Six sites relapsed with the same fungal species as that isolated at the start of the study. In this short-term assessment the relapse rate was not significantly associated with predisposing conditions. The tolerance was excellent in group A. Four patients (20%) in group B had mild (two patients) or moderate (two patients) burning and itching with each application. Twelve patients (30%) in group C had severe stinging and five of these patients who had perforated tympanic membranes also experienced pain. In terms of clinical and mycological effectiveness, there were no significant differences between the three treatment groups, although group A (ciclopiroxolamine cream 1%) and B (ciclopiroxolamine solution 1%) both showed significantly better tolerance (Fisher's test, P < 0.05) when compared with boric acid (group C).

[Dermatophytes isolated in Hospital Universitario 12 de Octubre (Madrid, Spain).]. / Cambios epidemiológicos observados en un decenio en las dermatofitosis del hospital universitario 12 de Octubre de Madrid: nuevas especies emergentes.

Over a 10 year period (January 1988 - December 1997), 3,241 dermatophyte strains were isolated from 18,465 specimens from patients in whom dermatophytosis was suspected clinically. This represents a 17.5% rate of isolation. Trichophyton rubrum (38.44%), Microsporum canis (28.75%), Epidermophyton floccosum (14.5%) and Trichophyton mentagrophytes (13.5%) were the dominant species, and Trichophyton tonsurans (2.09%) has emerged, whilst in the previous decade it had virtually disappeared. Our study is basically based on an out-patient selected population, and tinea corporis (30.79%), followed by tinea cruris (16.69%) and tinea unguium (16.69%) were the most prevalent clinical forms.

Prevalence of undetected tinea capitis in a prospective school survey in Madrid: emergence of new causative fungi.

From October 1994 to December 1996, a prospective study was undertaken in 10,000 unselected school children in Madrid, aged between 2 and 16 years (mean +/- SD 8.5 +/- 3.6 years). Fifty-two (0.52%) (including 13 immigrants from Africa) had dermatophytes in the scalp: 33 (0.33%) (including 10 immigrants from Africa) had tinea capitis and 19 were scalp carriers. Almost half of the symptomatic cases were caused by Trichophyton tonsurans (12 of 33 cases) and Microsporum canis (16 of 33 cases). T. tonsurans (13 of 19 cases) was the predominant species in the scalp carriers. Twenty-four per cent of the subjects with tinea capitis and 42% of the asymptomatic scalp carriers also had ringworm in other body sites. There was a significantly higher occurrence of tinea capitis (P < 0.001) (particularly due to T. tonsurans: P < 0.001) and of asymptomatic scalp carriers (P < 0.05) (particularly due to anthropophilic species: P < 0.01) in the immigrant population from Africa.

[Cutaneous zygomycosis caused by Rhizopus arrhizus in a surgical wound.]. / Zigomicosis cutánea por Rhizopus arrhizus en herida quirúrgica.

We report a case of cutaneous zygomycosis caused by Rhizopus arrhizus in a surgical wound following colostomy. The patient was a diabetic and in addition presented others risk factors. Zygomycosis was suspected when a necrotic wound surface appeared in the appropiate clinical setting. Diagnosis was confirmed on a combined histological and microbiological study. Extensive surgical resection, high doses of amphotericin B and treatment of the underlying conditions permitted the control of the infection.

Prevalence of undetected tinea capitis in a school survey in Spain.

From October 1994 to November 1995, a prospective study aiming to detect dermatophytes on the scalp was undertaken in 5000 unselected school children aged between 3 and 16 years (mean age 8.34 years, SD +/- 3.83). Thirty-two (0.64%) had dermatophytes in the scalp, 22. (0.44%) had tinea capitis and 10 were asymptomatic scalp carriers. It is important to point out that 33% of the patients with tinea capitis and 60% of the asymptomatic scalp carriers also had ringworm in other body sites. There was a significantly higher proportion of cases of tinea capitis (P < 0.001)(particularly due to Trichophyton tonsurans, P < 0.001) and of cases of asymptomatic scalp carriers (P < 0.05) (particularly due to Trichophyton tonsurans, P < 0.001) in the immigrant population of African origin. In all the child index cases with positive scalp cultures (tinea capitis and carriers), the household members were studied clinically and mycologically. One child had a body ringworm caused by Microsporum canis. Twelve adults had positive cultures with dermatophytosis (one tinea capitis and eleven body ringworm). Three adult patients were also carriers of dermatophytes in other body sites. Our data indicate a change in the causative agents of tinea capitis seen in Madrid over a 12-month period, with cases due to antropophilic species (T. tonsurans, T. soudanense, M. audouinii and T. violaceum) occurring in the immigrant population from Africa; as a consequence, there is an emergence of T. tonsurans in the Spanish population.

Cutaneous Alternaria alternata infection successfully treated with itraconazole.

A case of cutaneous alternariosis due to Alternaria alternata in a 47-year-old man who had the CREST (calcinosis, Raynaud's phenomenon, oesophageal dysfunction, sclerodactyly and telangiectasia) syndrome with pulmonary hypertension is presented. The patient, who lived in a rural area and was receiving prostacycline by continuous infusion, prednisone and azathioprine for his underlying disease, showed cutaneous lesions of the lower extremities spreading from the knees to the ankles. The patient was successfully treated with high doses of oral itraconazole.

[Zygomycosis: review of 16 cases]. / Zigomicosis: revisión de 16 casos.

BACKGROUND: Zygomycosis (mucormycosis or phycomycosis) is the infection caused by zygomycetes (non partitioned mycelial fungi, usually saprophytes). All cases of zygomycosis diagnosed in the Hospital 12 de Octubre in Madrid, Spain, from 1976 to 1994 were reviewed. METHODS: The underlying diseases of the patients, the factors favoring infection (alteration of the cutaneous barrier and administration of antimicrobians and corticosteroids) and the possible nosocomial origin of infection were analyzed. RESULTS: Over this period of time, 16 cases of zygomycosis were diagnosed with different clinical forms depending on the route of entry (rhino-orbital-cerebral, cutaneous or disseminated). The species isolated were Rhizopus oryzae, Rhizomucor pusillus, Absidia corymbifera and Rhizopus stolonifer. The species could not be determined in two cases. CONCLUSIONS: The diagnosis of zygomycosis should be based on a combined histological and microbiological study which allows both, differentiation between colonization and infection and isolation of the implicated species. Treatment is that of the underlying diseases, extensive surgical resection and amphotericin B.