Prevalence of co-existent COVID-19-associated pulmonary aspergillosis (CAPA) and its impact on early mortality in patients with COVID-19-associated pulmonary mucormycosis (CAPM).

BACKGROUND: Data on mixed mould infection with COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated pulmonary mucormycosis (CAPM) are sparse. OBJECTIVES: To ascertain the prevalence of co-existent CAPA in CAPM (mixed mould infection) and whether mixed mould infection is associated with early mortality (≤7 days of diagnosis). METHODS: We retrospectively analysed the data collected from 25 centres across India on COVID-19-associated mucormycosis. We included only CAPM and excluded subjects with disseminated or rhino-orbital mucormycosis. We defined co-existent CAPA if a respiratory specimen showed septate hyphae on smear, histopathology or culture grew Aspergillus spp. We also compare the demography, predisposing factors, severity of COVID-19, and management of CAPM patients with and without CAPA. Using a case-control design, we assess whether mixed mould infection (primary exposure) were associated with early mortality in CAPM. RESULTS: We included 105 patients with CAPM. The prevalence of mixed mould infection was 20% (21/105). Patients with mixed mould infection experienced early mortality (9/21 [42.9%] vs. 15/84 [17.9%]; p = 0.02) and poorer survival at 6 weeks (7/21 [33.3] vs. 46/77 [59.7%]; p = 0.03) than CAPM alone. On imaging, consolidation was more commonly encountered with mixed mould infections than CAPM. Co-existent CAPA (odds ratio [95% confidence interval], 19.1 [2.62-139.1]) was independently associated with early mortality in CAPM after adjusting for hypoxemia during COVID-19 and other factors. CONCLUSION: Coinfection of CAPA and CAPM was not uncommon in our CAPM patients and portends a worse prognosis. Prospective studies from different countries are required to know the impact of mixed mould infection.

Rapid prediction of lab-grown tissue properties using deep learning.

The interactions between cells and the extracellular matrix are vital for the self-organisation of tissues. In this paper we present proof-of-concept to use machine learning tools to predict the role of this mechanobiology in the self-organisation of cell-laden hydrogels grown in tethered moulds. We develop a process for the automated generation of mould designs with and without key symmetries. We create a large training set withN = 6400 cases by running detailed biophysical simulations of cell-matrix interactions using the contractile network dipole orientation model for the self-organisation of cellular hydrogels within these moulds. These are used to train an implementation of thepix2pixdeep learning model, with an additional 100 cases that were unseen in the training of the neural network for review and testing of the trained model. Comparison between the predictions of the machine learning technique and the reserved predictions from the biophysical algorithm show that the machine learning algorithm makes excellent predictions. The machine learning algorithm is significantly faster than the biophysical method, opening the possibility of very high throughput rational design of moulds for pharmaceutical testing, regenerative medicine and fundamental studies of biology. Future extensions for scaffolds and 3D bioprinting will open additional applications.

High-throughput design of cultured tissue moulds using a biophysical model: optimising cell alignment.

The technique presented here identifies tethered mould designs, optimised for growing cultured tissue with very highly-aligned cells. It is based on a microscopic biophysical model for polarised cellular hydrogels. There is an unmet need for tools to assist mould and scaffold designs for the growth of cultured tissues with bespoke cell organisations, that can be used in applications such as regenerative medicine, drug screening and cultured meat. High-throughput biophysical calculations were made for a wide variety of computer-generated moulds, with cell-matrix interactions and tissue-scale forces simulated using a contractile network dipole orientation model. Elongated moulds with central broadening and one of the following tethering strategies are found to lead to highly-aligned cells: (1) tethers placed within the bilateral protrusions resulting from an indentation on the short edge, to guide alignment (2) tethers placed within a single vertex to shrink the available space for misalignment. As such, proof-of-concept has been shown for mould and tethered scaffold design based on a recently developed biophysical model. The approach is applicable to a broad range of cell types that align in tissues and is extensible for 3D scaffolds.

Near Infrared Spectroscopy for Prediction of Yeast and Mould Counts in Black Soldier Fly Larvae, Feed and Frass: A Proof of Concept.

The use of black soldier fly larvae (BSFL) grown on different organic waste streams as a source of feed ingredient is becoming very popular in several regions across the globe. However, information about the easy-to-use methods to monitor the safety of BSFL is a major step limiting the commercialization of this source of protein. This study investigated the ability of near infrared (NIR) spectroscopy combined with chemometrics to predict yeast and mould counts (YMC) in the feed, larvae, and the residual frass. Partial least squares (PLS) regression was employed to predict the YMC in the feed, frass, and BSFL samples analyzed using NIR spectroscopy. The coefficient of determination in cross validation (R2CV) and the standard error in cross validation (SECV) obtained for the prediction of YMC for feed were (R2cv: 0.98 and SECV: 0.20), frass (R2cv: 0.81 and SECV: 0.90), larvae (R2cv: 0.91 and SECV: 0.27), and the combined set (R2cv: 0.74 and SECV: 0.82). However, the standard error of prediction (SEP) was considered moderate (range from 0.45 to 1.03). This study suggested that NIR spectroscopy could be utilized in commercial BSFL production facilities to monitor YMC in the feed and assist in the selection of suitable processing methods and control systems for either feed or larvae quality control.

Proteomics as a New-Generation Tool for Studying Moulds Related to Food Safety and Quality.

Mould development in foodstuffs is linked to both spoilage and the production of mycotoxins, provoking food quality and food safety concerns, respectively. The high-throughput technology proteomics applied to foodborne moulds is of great interest to address such issues. This review presents proteomics approaches useful for boosting strategies to minimise the mould spoilage and the hazard related to mycotoxins in food. Metaproteomics seems to be the most effective method for mould identification despite the current problems related to the bioinformatics tool. More interestingly, different high resolution mass spectrometry tools are suitable for evaluating the proteome of foodborne moulds able to unveil the mould's response under certain environmental conditions and the presence of biocontrol agents or antifungals, being sometimes combined with a method with limited ability to separate proteins, the two-dimensional gel electrophoresis. However, the matrix complexity, the high ranges of protein concentrations needed and the performing of multiple steps are some of the proteomics limitations for the application to foodborne moulds. To overcome some of these limitations, model systems have been developed and proteomics applied to other scientific fields, such as library-free data independent acquisition analyses, the implementation of ion mobility, and the evaluation of post-translational modifications, are expected to be gradually implemented in this field for avoiding undesirable moulds in foodstuffs.

The importance of appropriate processing and direct microscopic examination for the timely diagnosis and management of invasive infections caused by filamentous fungi.

The gold standard for diagnosis of invasive fungal infections caused by filamentous fungi remains the visualization of fungal elements in fluids, and biopsy/tissue collected from a normally sterile body site. Parallel recovery of viable fungus from the sample subsequently permits antifungal susceptibility testing of the individual isolate. Central to both processes is the appropriate processing of tissue specimens to avoid damaging fungal elements and optimize viable organism recovery. Historically, mycologists have proposed that homogenization (grinding or bead-beating) of tissue should be avoided in cases of suspected fungal infection as it likely damages hyphae, instead preferring to chop tissue into small portions (dicing) for direct microscopic examination and culture. Here, we have compared the two processes directly on material from clinical patient cases of mucoromycosis and invasive aspergillosis. Representative portions of fresh biopsy samples were processed in parallel either by chopping (dicing) in the mycology reference laboratory or by bead-beating in the adjoining general microbiology laboratory. Aliquots of the samples were then cultured under identical conditions and subjected to direct microscopic examination. The results demonstrated that tissue homogenization significantly reduced (i) organism recovery rates in cases of both mucoromycosis and invasive aspergillosis and (ii) the number of fungal elements detectable upon direct microscopic examination. To our knowledge, this is the first study to directly compare these alternative processing methods and despite only employing a limited number of samples the data presented here, provide support for the perceived mycological wisdom that homogenization of tissue samples should be avoided when filamentous fungal infections are suspected.

The gold standard for diagnosis of fungal infections remains the visualization of fungal elements in samples from usually sterile sites. Here we show that certain methods employed for processing biopsy samples significantly impact the ability to detect and grow fungi from genuine cases of infection.

"Ethno-microbiology" of ethnic Indian fermented foods and alcoholic beverages.

The concept of "ethno-microbiology" is to understand the indigenous knowledge of the Indian people for production of culturally and organoleptically acceptable fermented foods by natural fermentation. About 1000 types of common, uncommon, rare, exotic and artisan fermented foods and beverages are prepared and consumed in different geographical regions by multi-ethnic communities in India. Indian fermented foods are mostly acidic and some are alkaline, along with various types of alcoholic beverages. A colossal diversity of microorganisms comprising bacteria mostly belongs to phylum Firmicutes, filamentous moulds and enzyme- and alcohol-producing yeasts under phyla Ascomycota and Mucoromycota, and few bacteriophages and archaea have been reported from Indian fermented foods. Some microorganisms associated with fermented foods have functionalities and health promoting benefits. "Ethno-microbiology" of ethnic Indian people has exhibited the proper utilisation of substrates either singly or in combination such as fermented cereal-legume mixture (idli, dosa and dhokla) in South and West India, sticky fermented soybean food (kinema and related foods), fermented perishable leafy vegetable (gundruk and related foods), fermented bamboo shoots (soibum and related foods) and fermented fish (ngari and others) in North East India, and fermented meat and sausage-like products in the Indian Himalayas, fermented coconut beverage (toddy) in coastal regions, and various types of naturally fermented milk products (dahi and related products) in different regions of India. This review has also highlighted the "ethno-microbiology" knowledge of the people involving the consortia of essential microorganisms in traditionally prepared amylolytic starters for production of cereal-based alcoholic beverages. The novelty of this review is the interpretation of ethno-microbiological knowledge innovated by ethnic Indian people on the use of beneficial microorganisms for food fermentation to obtain the desired fermented food products for consumption.

Real-life applicability of the Euroarray dermatomycosis kit in the diagnosis of onychomycosis.

BACKGROUND: Traditionally, KOH microscopy and fungal culture are the two preferred tests as gold standard for diagnosis of onychomycosis. Recently, other diagnostic methods have been developed to improve the microbiological diagnosis. The EUROArray dermatomycosis kit is a PCR-based microarray test system for the detection and direct identification of species that are most frequently involved in skin and nail infections. OBJECTIVES: Our primary aim was to evaluate the real-life applicability of the EUROArray dermatomycosis kit in the diagnosis of onychomycoses. In addition, we compared the aetiology of onychomycoses found in our patients with those described in the literature. PATIENTS/METHODS: We prospectively studied consecutive 100 patients with suspected onychomycoses. Samples of suspect toenails were taken as part of routine medical management. Nail specimens were evaluated by means of three diagnostic methods: KOH preparation, culture and EUROArray dermatomycosis kit. RESULTS: Onychomycosis was diagnosed in 47/100 patients who proved positive on at least one reference diagnostic test and in 49/100 patients who proved positive on PCR. The combination of microscopy and PCR had better sensitivity than microscopy (p = .0397), fungal culture (p = .0061) and PCR alone (p = .0117). Moulds were more frequently positive in culture than in PCR (p = .033). Dermatophytes proved positive more frequent than moulds and yeasts in both culture and PCR; in particular, Trichophyton interdigitale was the most frequent pathogen. CONCLUSIONS: In conclusion, introducing EUROArray dermatomycosis kit into the diagnostic algorithm of onychomycosis increases the sensitivity of direct microscopy and yields more rapid results than culture.

Advances in understanding the enzymatic potential and production of ochratoxin A of filamentous fungi isolated from cocoa fermented beans.

In this work, we determined the degree of filamentous fungi contamination in cocoa fermented seeds and the fungal potential to produce enzymes that could contribute to the cocoa quality. Internal transcribed spacer amplicon sequencing (ITS) showed 11 different species with Byssochlamys spectabilis, Aspergillus niger, Aspergillus flavus, Aspergillus carbonarius, Circinella muscae and Penicillium citrinum as the most abundant species. Our results evidenced intra and inter-species differences in the enzymes production. Cellulases, ß-glucosidase, ornithine decarboxylase and phenylalanine decarboxylase were the most diffused enzymes expressed in the 53 strains here studied. Moreover, A. niger (6/12), A. carbonarius (2/3), and P. citrinum (3/3) showed high pectinolytic activity. Remarkable was the amino decarboxylase activity of P. citrinum, and A. flavus strains. For the first time we reported the presence of B. spectabilis in cocoa fermented beans, which could play an important role in the biogenic amines formation. In addition, we explored the capability of the Aspergillus section Nigri strains, to produce ochratoxin A (OTA) in a cacao model system (CPMS) and in malt extract medium (MEL). We observed that CPMS, but not MEL, stimulated the OTA production in 6 out 15 strains of Aspergillus section Nigri, reaching values ranging between 1.70 and 4995 µg OTA kg-1 dry mycelium.

Human mucosal-associated invariant T cells respond to Mucorales species in a MR1-dependent manner.

Activation of mucosal-associated invariant T cells (MAIT cells) by certain bacteria, viruses, and yeast is well studied, but the activation potential of filamentous moulds from the order Mucorales is not known. Here, we show a rapid response of human MAIT cells against the Mucorales species Mucor circinelloides, Rhizopus arrhizus, and Rhizopus microsporus. This activation included upregulation of CD69 and degranulation marked by increased CD107a expression, while intracellular perforin and granzyme A expression were reduced. Furthermore, blocking of the antigen-presenting molecule major histocompatibility complex class I-related abrogated MAIT cell activation demonstrating a T cell receptor-dependent stimulation by Mucorales.

Microbiological assessment of liquid feed for finisher pigs on commercial pig units.

AIMS: To investigate the microbiological and nutritional quality of liquid finisher pig feed on commercial production units and the factors influencing this. METHODS AND RESULTS: Microbiological and physio-chemical analyses were performed on liquid feed sampled from the mixing tank and troughs of the finisher section of eight commercial pig units. Lactic acid bacteria, yeast and Escherichia coli counts, as well as lactic acid, ethanol and acetate concentrations were higher in residual feed sampled from the troughs compared with mixing tank samples (P < 0·001). Feed pH, as well as lysine, methionine and threonine concentrations and gross energy were all lower in the residual trough samples (P < 0·001). Liquid co-products reduced E. coli counts in the residual trough samples (P < 0·05), pH in the mixing tank (P < 0·01) and fresh trough samples (P < 0·05) and mould counts at all three sampling locations (P < 0·01) but sanitation practices had no impact. CONCLUSIONS: Even when considered unfermented, a considerable degree of spontaneous fermentation occurs in liquid feed, with resultant negative effects on nutritional quality. SIGNIFICANCE AND IMPACT OF THE STUDY: This is one of the first studies showing that uncontrolled fermentation of fresh liquid pig feed is commonplace on commercial units, highlighting the need for implementation of suitable control strategies.

Serum levels of IgG antibodies against Aspergillus fumigatus and the risk of hypersensitivity pneumonitis and other interstitial lung diseases.

Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD) caused by the inhalation of antigens. Antigen-specific IgG antibodies (sIgG) are used as biomarkers of exposure when diagnosing HP, but little is known about the longitudinal relation between antibody levels and risk of HP or other ILD. In a follow-up design, we explored the relationship between sIgG antibodies against Aspergillus fumigatus and the diagnosis of HP in 647 subjects suspected of HP. We showed that IgG levels above the reference value resulted in a hazard ratio of 9.5 for subsequent HP. Our findings support a relationship between high levels of sIgG against A. fumigatus and risk of HP.

Epidemiological analysis of nail aspergillosis and non-dermatophyte moulds. Criteria for the involvement of Aspergillus in 102 cases of onychomycosis at Montpellier University Hospital, France (1991-2019).

BACKGROUND: Moulds are often wrongly considered contaminants, not very sensitive to conventional antifungal treatments, but they may cause ungual hyphomycosis, particularly Aspergillus. Due to the lack of precise diagnostic criteria, their real impact is underestimated. OBJECTIVES: Retrospective descriptive analysis of all ungual hyphomycosis cases diagnosed at Montpellier Hospital from 1991 to 2019 to: (i) determine the incidence of onychomycosis by pseudo-dermatophytes and moulds; (ii) perform an epidemiological analysis of nail aspergillosis; and (iii) provide simple criteria for mould involvement in onychopathy. PATIENTS/METHODS: Data concerning 4053 patients were collected: age, sex, onychomycosis location, direct examination results, species(s) identified and fungal co-infections. Moreover, clinical data of patients with nail aspergillosis were analysed to identify potential contributing factors, and the classical criteria for mould involvement in onychopathy were critically reviewed. RESULTS: A pseudo-dermatophyte or a mould was involved in nail colonisation in 17.25% of patients (men/women ratio: 0.70; mean age: 53.1 years). The identified hyphomycetes belonged mainly to the genera Fusarium (45.68%), Scopulariopsis (30.23%) and Aspergillus (16.94%). Analysis of the clinical reports of 102 patients with ungual aspergillosis (men/women ratio: 0.67; mean age: 56.3 years) identified cardiovascular (43.9%), endocrine (25.8%), cancer (19.7%) and skin (18.2%) diseases as contributing factors. CONCLUSIONS: The adoption of simple and reliable criteria (ie, characteristic filaments on direct microscopic examination after periodic acid-Schiff staining, growth at seeding points in culture) allows determining the formal involvement of a mould in chronic onychopathies and avoiding possible side effects and costs of empirical or inappropriate and repetitive treatments.

Diversity of yeasts and moulds in dairy products from Umbria, central Italy.

In this research communication we report on the diversity of yeast and mould species in 69 samples of milk and different dairy products from three plants located in Umbria, central Italy. Isolates were characterised both macroscopically and microscopically and then identified by PCR and genome sequencing of the ITS region and the D1-D2 domain of the large-subunit rRNA gene for filamentous fungi and yeasts, respectively. Out of the 69 samples analysed, 51 (73.9%) tested positive for the presence of yeasts, whereas moulds were detected in 25 (36.2%) samples. A total of 9 yeast species belonging to 8 different genera and 13 mould species belonging to 6 different genera were isolated. The most common genera isolated were Debaryomyces and Kluyveromyces among the yeasts and Penicillium and Galactomyces among the moulds. Microbiota play a key role in the formation of flavour, aroma, texture and appearance of dairy products. This complex microbial ecosystem includes both cultured and external bacteria, yeasts and moulds. Some of them have an important role in the production of cheeses, whereas others are responsible for dairy product spoilage, resulting in significant food waste and economic losses. Some species can produce mycotoxins, representing a potential hazard for the consumer's safety. This study provides interesting information on the diversity of fungi species in dairy products from central Italy that can be of major importance to identify these products and to develop adequate strategies for fungal spoilage control and consumer safety.

High-dose-rate brachytherapy for non-melanoma skin cancer using tailored custom moulds - a single-centre experience.

AIM OF THE STUDY: The aim of this retrospective study was to analyse tumour control, toxicity, and aesthetic outcome of patients affected by non-melanoma skin cancer (NMSC) treated with 192 Ir high-dose-rate (HDR)-brachytherapy (BT) at the Division of Radiotherapy, University of Pisa. MATERIAL AND METHODS: From January 2014 to December 2019 we treated 37 patients (median age 79 years; range 31-91 years) affected by NMSC, with the following histological subtypes: 62.2% basal cell carcinoma and 37.8% squamous cell carcinoma. We analysed 40 lesions with a depth ≤ 5 mm, located in 40.0% scalp, 17.5% nose, 25.0% face, and 17.5% ear, all treated with 192 Ir-based HDR-BT, using tailored custom moulds, with a median of 5 catheters (range, 1-9) spaced 1 cm apart. The most common fractionation scheme was 40 Gy in 8 daily fractions; the biological effective dose was 60 Gy. RESULTS: The median follow-up was 25 months (range, 3-70 months). The 2-year local control rate was 90%. Common terminology criteria for adverse event (CTCAE vs. 5.0) G1 toxicities were dermatitis (52%), pain (25%), and ulceration (22%). The only G2 acute toxicities were dermatitis and ulceration. The most common G1 late toxicities were fibrosis (17%), atrophy (15%), and hypopigmentation (12%). No G3 or higher acute or late toxicity was reported. Excellent cosmetic results were observed in 65.0% of the lesions; only 1 case (2.5%) reported a poor cosmetic result. CONCLUSIONS: Surface mould HDR-BT is a safe, effective, and well tolerated treatment modality for NMSC and can be considered a good alternative, especially for elderly patients who are often unfit for surgery.

Silage fermentation-updates focusing on the performance of micro-organisms.

Advances in micro-organism identification techniques have resulted in increased knowledge of the diversity of prokaryotes and eukaryotes in silage. Such knowledge has enhanced the understanding of how fermentation occurs in forage crops with different characteristics and how the process can be improved to enhance silage quality. Undesirable micro-organisms can grow in silage when fermentation does not occur properly. Such micro-organisms may be pathogenic and/or produce toxic metabolic compounds; however, information on the consequences of these metabolites on the health of animals that consume silage is still lacking. The major challenge of ensilage is to produce high-quality feed that is nutritional, sanitary and stable, with a high dry matter recovery rate, in a process involving no interventions during fermentation and considerable variation in the characteristics of the substrates. It is important to note that each substrate has particularities and that we can only improve fermentation if we fully understand microbial diversity. This review is intended to update information related to the fermentation profile of silage, focusing on microbial diversity.

Evolution of lifestyles in Capnodiales.

The Capnodiales, which includes fungi known as the sooty moulds, represents the second largest order in Dothideomycetes, encompassing morphologically and ecologically diverse fungi with different lifestyles and modes of nutrition. They include saprobes, plant and human pathogens, mycoparasites, rock-inhabiting fungi (RIF), lichenised, epi-, ecto- and endophytes. The aim of this study was to elucidate the lifestyles and evolutionary patterns of the Capnodiales as well as to reconsider their phylogeny by including numerous new collections of sooty moulds, and using four nuclear loci, LSU, ITS, TEF-1α and RPB2. Based on the phylogenetic results, combined with morphology and ecology, Capnodiales s. lat. is shown to be polyphyletic, representing seven different orders. The sooty moulds are restricted to Capnodiales s. str., while Mycosphaerellales is resurrected, and five new orders including Cladosporiales, Comminutisporales, Neophaeothecales, Phaeothecales and Racodiales are introduced. Four families, three genera, 21 species and five combinations are introduced as new. Furthermore, ancestral reconstruction analysis revealed that the saprobic lifestyle is a primitive state in Capnodiales s. lat., and that several transitions have occurred to evolve lichenised, plant and human parasitic, ectophytic (sooty blotch and flyspeck) and more recently epiphytic (sooty mould) lifestyles.

Characteristics and risk factors for mortality of invasive non-Aspergillus mould infections in patients with haematologic diseases: A single-centre 7-year cohort study.

Since mould-active azole prophylaxis has become a standard approach for patients with high-risk haematologic diseases, the epidemiology of invasive fungal infections (IFIs) has shifted towards non-Aspergillus moulds. It was aimed to identify the epidemiology and characteristics of non-Aspergillus invasive mould infections (NAIMIs). Proven/probable NAIMIs developed in patients with haematologic diseases were reviewed from January 2011 to August 2018 at Catholic Hematology hospital, Seoul, Korea. There were 689 patients with proven/probable invasive mould infections; of them, 46 (47 isolates) were diagnosed with NAIMIs. Fungi of the Mucorales order (n = 27, 57.4%) were the most common causative fungi, followed by Fusarium (n = 9, 19.1%). Thirty-four patients (73.9%) had neutropenia upon diagnosis of NAIMIs, and 13 (28.3%) were allogeneic stem cell transplantation recipients. The most common site of NAIMIs was the lung (n = 27, 58.7%), followed by disseminated infections (n = 8, 17.4%). There were 23.9% (n = 11) breakthrough IFIs, and 73.9% (n = 34) had co-existing bacterial or viral infections. The overall mortality at 6 and 12 weeks was 30.4% and 39.1%, respectively. Breakthrough IFIs (adjusted hazards ratio [aHR] = 1.99, 95% CI: 1.3-4.41, P = .031) and surgical treatment (aHR = 0.09, 95% CI: 0.02-0.45, P = .003) were independently associated with 6-week overall mortality. NAIMIs were not rare and occur as a complex form of infection often accompanied by breakthrough/mixed/concurrent IFIs and bacterial or viral infections. More active diagnostic efforts for NAIMIs are needed.

Non-Aspergillus invasive mould infections in patients treated with ibrutinib.

BACKGROUND: Invasive mould infections (IMIs) are very rare in patients with lymphoid malignancies. However, IMIs, mostly due to Aspergillus species, have been increasingly reported in such patients receiving ibrutinib (IBR). There is paucity of information regarding non-Aspergillus invasive mould infections (NAIMIs) in this setting, OBJECTIVES: To review our recent experience and the published literature on the topic. PATIENTS/METHODS: We present a case of invasive sinusitis caused by Fusarium in a patient with refractory chronic lymphocytic leukaemia (CLL) who was treated with IBR and review the 12 published cases of NAIMIs during IBR. RESULTS: Nearly all cases of NAIMIs in the setting of IBR use were encountered in patients with CLL. Mixed fungal infections, brain involvement and late-onset infections were common. CONCLUSIONS: Although rare, NAIMIs should be considered in patients who receive IBR.

Phenotypic variability predicts decision accuracy in unicellular organisms.

When deciding between different options, animals including humans face the dilemma that fast decisions tend to be erroneous, whereas accurate decisions tend to be relatively slow. Recently, it has been suggested that differences in the efficacy with which animals make a decision relate closely to individual behavioural differences. In this paper, we tested this hypothesis in a unique unicellular organism, the slime mould Physarum polycephalum. We first confirmed that slime moulds differed consistently in their exploratory behaviour from 'fast' to 'slow' explorers. Second, we showed that slow explorers made more accurate decisions than fast explorers. Third, we demonstrated that slime moulds integrated food cues in time and achieved higher accuracy when sampling time was longer. Lastly, we showed that in a competition context, fast explorers excelled when a single food source was offered, while slow explorers excelled when two food sources varying in quality were offered. Our results revealed that individual differences in accuracy were partly driven by differences in exploratory behaviour. These findings support the hypothesis that decision-making abilities are associated with behavioural types, even in unicellular organisms.