Developing collaborative works for faster progress on fungal respiratory infections in cystic fibrosis.

Cystic fibrosis (CF) is the major genetic inherited disease in Caucasian populations. The respiratory tract of CF patients displays a sticky viscous mucus, which allows for the entrapment of airborne bacteria and fungal spores and provides a suitable environment for growth of microorganisms, including numerous yeast and filamentous fungal species. As a consequence, respiratory infections are the major cause of morbidity and mortality in this clinical context. Although bacteria remain the most common agents of these infections, fungal respiratory infections have emerged as an important cause of disease. Therefore, the International Society for Human and Animal Mycology (ISHAM) has launched a working group on Fungal respiratory infections in Cystic Fibrosis (Fri-CF) in October 2006, which was subsequently approved by the European Confederation of Medical Mycology (ECMM). Meetings of this working group, comprising both clinicians and mycologists involved in the follow-up of CF patients, as well as basic scientists interested in the fungal species involved, provided the opportunity to initiate collaborative works aimed to improve our knowledge on these infections to assist clinicians in patient management. The current review highlights the outcomes of some of these collaborative works in clinical surveillance, pathogenesis and treatment, giving special emphasis to standardization of culture procedures, improvement of species identification methods including the development of nonculture-based diagnostic methods, microbiome studies and identification of new biological markers, and the description of genotyping studies aiming to differentiate transient carriage and chronic colonization of the airways. The review also reports on the breakthrough in sequencing the genomes of the main Scedosporium species as basis for a better understanding of the pathogenic mechanisms of these fungi, and discusses treatment options of infections caused by multidrug resistant microorganisms, such as Scedosporium and Lomentospora species and members of the Rasamsonia argillacea species complex.

[Identifying potentially inappropriate prescriptions in patients over 65 years-old using original Beers criteria and their Spanish adaptation]. / Prescripción potencialmente inadecuada en mayores de 65 años según los criterios de Beers originales y su versión adaptada.

OBJECTIVE: To compare the detection of potentially inappropriate medication (PIM) using the original Beers criteria, a global reference for evaluating prescriptions in the elderly, and their Spanish version. DESIGN: Retrospective observational study LOCATION: A Primary Care area in the province of Murcia, Spain. PARTICIPANTS: A total of 7,856 subjects aged 65 and over, with at least one drug prescribed in a Primary Care Area of Spain during study period. METHOD: Illnesses and treatments registered in the Primary Care computerised medical history of patients were analysed during a 12month study period (2012). The original Beers criteria and their Spanish adaptation were used to evaluate PIM, considering both sets of criteria overall, and individually. RESULTS: The median age of the patients was 76.0years, with the majority females (56.6%). Patients received a median of 13 active substances and 66 medical prescriptions. The percentage of patients prescribed PIM ranged from 44.8% according to the original Beers criteria to 49.4% with the Spanish adaptation. CONCLUSIONS: PIMs are frequent in our context. The original Beers criteria, if not adapted to the local drug catalogue, underestimated the frequency of PIM in the elderly population studied.

Pithomyces species (Montagnulaceae) from clinical specimens: identification and antifungal susceptibility profiles.

The fungal genus Pithomyces comprises numerous dematiaceous saprobic species commonly found on dead leaves and stems of a great variety of plants. Occasionally, they have been recovered from clinical specimens. We morphologically and molecularly (rDNA sequences) investigated a set of 42 isolates tentatively identified as Pithomyces recovered from clinical specimens in the United States. The predominant species were P. chartarum and P. sacchari (33.3% each), followed by Pithomyces sp. I (28.6%) and P. maydicus (4.8%). Most of the isolates were obtained from samples of superficial tissue (50%), the respiratory tract (21.4%), and the nasal region (19%). In general, these fungi were highly susceptible in vitro to the eight antifungal agents tested.

Mucormycosis in children: a study of 22 cases in a Mexican hospital.

We present a single-centre, retrospective study (1985-2012) of 22 cases of mucormycosis in children. A total of 158 mucormycosis cases were identified, of which 22 (13.96%) were children. The mean age of the children was 10.3 years (range: 6 months-18 years), and 59% of the infections occurred in males. The rhinocerebral form was the main clinical presentation (77.27%), followed by the primary cutaneous and pulmonary patterns. The major underlying predisposing factors were diabetes mellitus in 68.18% of the patients and haematologic diseases in 27.7% of the patients. The cases were diagnosed by mycological tests, with positive cultures in 95.4% of the patients. Rhizopus arrhizus was the foremost aetiologic agent in 13/22 cases (59.1%). In 21 cultures, the aetiologic agents were identified morphologically and by molecular identification. In 10 cultures, the internal transcribed spacer region of the ribosomal DNA was sequenced. Clinical cure and mycological cure were achieved in 27.3% cases, which were managed with amphotericin B deoxycholate and by treatment of the underlying conditions.

Acremonium with catenate elongate conidia: phylogeny of Acremonium fusidioides and related species.

Acremonium is one of the largest and most complex genera of hyphomycetes. Its taxonomy is not yet resolved and the phylogenetic value of the most distinctive morphological features is unknown. The species of this genus produce conidia in chains or form slimy heads or both. We have studied a set of clinical and environmental Acremonium strains morphologically characterized by producing mostly catenate, elongate, more or less fusiform conidia. Based on phenotypic data and in the analysis of the sequences of the ITS region, the D1/D2 domains of the 28S rRNA gene and a fragment of the ß-tubulin gene, three new species morphologically similar to Acremonium fusidioides and belonging to the family Bionectriaceae (Hypocreales) are described and illustrated; they are Acremonium pilosum, Acremonium parvum and Acremonium citrinum. The first species produces two kinds of conidia: clavate with smooth walls and globose with abundant filiform projections. Acremonium parvum is characterized by slow growth and pyriform or slightly lanceolate conidia with an elongate and truncate base. Acremonium citrinum produces a diffusible yellow pigment and obovoid conidia.

In vitro antifungal susceptibility of clinically relevant species belonging to Aspergillus section Flavi.

The in vitro antifungal susceptibility of 77 isolates belonging to different clinically relevant species of Aspergillus section Flavi, including those of different phylogenetic clades of A. flavus, was tested for nine antifungal agents using a microdilution reference method (CLSI, M38-A2). Terbinafine and the echinocandins demonstrated lower MICs/MECs for all species evaluated, followed by posaconazole. Amphotericin B showed MICs ≥ 2 µg/ml for 38 (49.4%) of the 77 isolates tested.

Coniochaeta polymorpha, a new species from endotracheal aspirate of a preterm neonate, and transfer of Lecythophora species to Coniochaeta.

A new species of Coniochaeta from endotracheal secretion of a preterm neonate, Coniochaeta polymorpha, is described. This anamorphic species is characterized by development of dark brown colonies after 1 week of incubation on culture medium, formation of abundant yeast-like cells and sclerotium-like structures producing discrete, brown, nearly globose phialidic conidiogenous cells and absence of chlamydospores. A combined sequence dataset of the ITS region, partial LSU rDNA, actin and ß-tubulin genes sufficiently resolved the unique phylogenetic status of this species. In response to recent changes in the nomenclature for pleomorphic fungi, we transfer the Lecythophora species to Coniochaeta, and propose the following new combinations: Coniochaeta canina, Coniochaeta cateniformis, Coniochaeta decumbens, Coniochaeta fasciculata, Coniochaeta hoffmannii, Coniochaeta lignicola, Coniochaeta luteorubra, Coniochaeta luteoviridis and Coniochaeta mutabilis.

Polyphasic analysis of Purpureocillium lilacinum isolates from different origins and proposal of the new species Purpureocillium lavendulum.

Purpureocillium is a genus recently proposed to accommodate Paecilomyces lilacinus, a well studied species that has biotechnological properties and an ability to cause human infections. Since contradictory data have been reported on the intraspecific genetic variability of P. lilacinum, we have carried out a polyphasic study of a set of clinical and environmental isolates of this species. Detailed morphological examination and sequence analysis of four different loci, including the ribosomal internal transcribed spacer, the domains D1 and D2 of the 28S rDNA, EF-1a and the largest subunit of RNA polymerase II (rpb1), showed that P. lilacinum formed a well supported phylogenetic clade with low intraspecific variability. The new species Purpureocillium lavendulum, which has vinaceous colonies similar to those of P. lilacinum, is proposed. It is characterized by the lack of growth at 35 C, the production of a yellow diffusible pigment and by subglobose or limoniform conidia.

Phialemoniopsis, a new genus of Sordariomycetes, and new species of Phialemonium and Lecythophora.

In molecular studies involving numerous clinical isolates of the genera Acremonium, Phialemonium and Lecytophora some of them could not be identified. To clarify the phylogenetic relationships among these fungi and other related taxa, we performed a polyphasic study based on a detailed morphological study and on the analysis of sequences of four loci: the internal transcribed spacer regions, the D1/D2 domains of the 28S rRNA, actin and ß-tubulin genes. The combination of the resulting data let us propose the new genus Phialemoniopsis to accommodate the opportunistic fungi Phialemonium curvatum and Sarcopodium oculorum and two new species, Phialemoniopsis cornearis and Phialemoniopsis pluriloculosa. The taxonomy of Phialemoniopsis has not been completely resolved, however, remaining incertae sedis within the Sordariomycetes. In addition, the new species Lecythophora luteorubra, Lecythophora cateniformis and Phialemonium globosum are described and the species Acremonium atrogriseum and Taifanglania inflata are transferred to the genus Phialemonium. Lecythophora and Phialemonium are currently monophyletic genera of the families Coniochaetaceae (Coniochaetales) and Cephalothecaceae (Sordariales) respectively, according to our results. Tables summarizing key morphological features to distinguish the current species of Lecythophora, Phialemonium and Phialemoniopsis are provided.

Rare arthroconidial fungi in clinical samples: Scytalidium cuboideum and Arthropsis hispanica.

We report the presence of the two arthroconidial anamorphic fungi, Scytalidium cuboideum and Arthropsis hispanica, in clinical samples from the USA. Both fungi were morphologically and molecularly identified. The antifungal susceptibility of four isolates of A. hispanica and five of S. cuboideum to eight antifungal drugs is provided.

Molecular identification and in vitro response to antifungal drugs of clinical isolates of Exserohilum.

Exserohilum is an agent of human and animal mycoses. Although classification has been based on a few subtle morphological differences, three species of clinical interest have been traditionally accepted. In this study, by using a multigene sequence analysis, we have demonstrated that Exserohilum longirostratum and E. mcginnisii are probable synonyms of E. rostratum. The isolates tested were mainly from the nasal region. Antifungal susceptibility testing demonstrated high activity of the eight agents tested against this fungus.

Molecular identification and antifungal susceptibility testing of clinical isolates of the Candida rugosa species complex and proposal of the new species Candida neorugosa.

Candida rugosa is a poorly known fungal species occasionally involved in human infections. A molecular analysis of the sequences of the D1/D2 domains and the internal transcribed spacer (ITS) region of the ribosomal genes of 24 clinical isolates phenotypically identified as C. rugosa demonstrated that only 10 (41.6%) isolates belonged to that species. The other isolates were identified as Candida pararugosa (41.6%) and Candida pseudorugosa (8.3%). The remaining two isolates, from human and equine infections, respectively, were clearly different from the others and represent a new species proposed here as Candida neorugosa. The closest species by D1/D2 sequences was the type strain of C. rugosa, with only 92.3% similarity. C. neorugosa can also be differentiated from all other species of the C. rugosa complex by phenotypic features. The eight antifungal drugs tested showed high in vitro activity against the 24 isolates included in the study.

Aspergillus novoparasiticus: a new clinical species of the section Flavi.

During a survey on the incidence of Aspergillus in clinical environments, we found some interesting isolates that were morphologically similar to Aspergillus parasiticus, but differed in the color of the colonies and in the pattern of their conidial ornamentation. In the present study, those isolates were characterized using a polyphasic approach. A phylogenetic analysis was carried out, based on partial fragments of the acetamidase (amdS) and O-methyltransferase (omtS) genes and the internal transcribed spacer (ITS) region of rDNA. This information was combined with a detailed morphological and physiological study that included aflatoxin production and assimilation profiles of different carbon and nitrogen sources. The phenotypic and genotypic results support the proposal of a new species, Aspergillus novoparasiticus, phylogenetically placed in a distinct sister clade to that of A. parasiticus. The former has lobate-reticulate conidia and does not produce aspergillic acid on AFPA or organic acids on CREA, while A. parasiticus has echinulate conidia and produces aspergillic and organic acids. In addition, this new species, as well as A. parasiticus, produces aflatoxins B1, B2, G1 and G2.

Two new species of Acremonium from Spanish soils.

In a survey on the diversity of microfungi in Spanish soils, two new species of Acremonium were found. Both species were characterized as having more or less erect, mostly branched conidiophores bearing whorls of acicular phialides. In addition, one of these species, Acremonium asperulatum, produced abundant chlamydospores and globose rough-walled conidia. The other species, Acremonium variecolor, produced a brownish diffusible pigment and smooth-walled, subglobose conidia with apiculate base; sessile conidia inserted directly on vegetative hyphae also were present. The analysis of the sequences of the ITS region, the D1/D2 domains of the 28S rRNA gene and a fragment of the actin gene revealed relationships of both species with members of the Bionectriaceae (Hypocreales). Genetic differences were observed with morphologically similar species.

Two new species of Mucor from clinical samples.

Two new species in the order Mucorales, Mucor velutinosus and Mucor ellipsoideus, isolated from human clinical specimens in the USA, are described and illustrated. The former species is similar to Mucor ramosissimus, from which it can be differentiated by its ability to grow at 37°C and produce verrucose sporangiospores. Mucor ellipsoideus is also able to grow and sporulate at 37°C like M. indicus, the nearest phylogenetic species in this study, however, the former has narrow ellipsoidal sporangiospores in contrast to the subglobose to ellipsoidal sporangiospores of M. indicus. Analysis of the sequences of the ITS and the D1-D2 regions of the rRNA genes confirmed the novelty of these species. The in vitro antifungal susceptibility of the new species showed that amphotericin B was active against all isolates and posaconazole and itraconazole showed low activity.

Two new species of Cladorrhinum.

Two new species of Cladorrhinum, C. flexuosum and C. microsclerotigenum, are described and their sequences of the 5.8S and 28S ribosomal DNA and internal transcribed spacers 1 and 2 of the ribosomal RNA gene cluster analyzed. Cladorrhinum flexuosum, isolated from soil in Spain, forms fast-growing, dull yellow colonies, flexuous conidiophores and globose to dacryoid conidia. Cladorrhinum microsclerotigenum, isolated from Musa sp. in Turkey, strongly resembles Cladorrhinum phialophoroides in the production of abundant terminal phialides, ellipsoid conidia and microsclerotia in culture. It differs from C. phialophoroides in its ability to grow at 36 C and high number of intercalary phialides, which only infrequently occur in C. phialophoroides.

Saccharomyces cerevisiae vaginitis: microbiology and in vitro antifungal susceptibility.

Genitourinary infections by Saccharomyces cerevisiae are rare. Here, we describe eight S. cerevisiae vulvovaginitis episodes where molecular (Affirm VPIII) and conventional microbiological methods (culture and carbohydrate assimilation) have proven to be inadequate for diagnostic purposes. DNA sequencing allowed the correct identification of the pathogen. All isolates were susceptible to most antifungal agents, with two of them also found to be susceptible-dose-dependent to itraconazole.

Heterothallism in Scedosporium apiospermum and description of its teleomorph Pseudallescheria apiosperma sp. nov.

Scedosporium apiospermum has traditionally been thought of as the anamorph of Pseudallescheria boydii (Microascaceae, Ascomycota), but recent molecular studies has demonstrated that they are different species. Since a teleomorph was not observed among isolates recently identified as S. apiospermum, we investigated whether this species could be heterothallic. In this study, 15 isolates of S. apiospermum were paired in all possible combinations, including self-pairings. Several combinations produced fertile ascomata typical of the genus Pseudallescheria, while all isolates were self-sterile. The isolates were grouped into two different mating types. Crosses among F1 progeny ascospores demonstrated a bi-allelic heterothallic mating system. The new species Pseudallescheria apiosperma, teleomorph of S. apiospermum, is proposed and described.

Molecular phylogenetic diversity of the emerging mucoralean fungus Apophysomyces: proposal of three new species.

BACKGROUND: Apophysomyces is a monotypic genus belonging to the order Mucorales. The species Apophysomyces elegans has been reported to cause severe infections in immunocompromised and immunocompetent people. In a previous study of Alvarez et al.(3) [J Clin Microbiol 2009;47:1650-6], we demonstrated a high variability among the 5.8S rRNA gene sequences of clinical strains of A. elegans. MATERIAL AND METHODS: We performed a polyphasic study based on the analysis of the sequences of the histone 3 gene, the internal transcribed spacer region of the rDNA gene, and domains D1 and D2 of the 28S rRNA gene, as well as by evaluation of some relevant morphological and physiological characteristics of a set of clinical and environmental strains of A. elegans. RESULTS AND CONCLUSIONS: We have demonstrated that A. elegans is a complex of species. We propose as new species Apophysomyces ossiformis, characterised by bone-shaped sporangiospores, Apophysomyces trapeziformis, with trapezoid-shaped sporangiospores, and Apophysomyces variabilis, with variable-shaped sporangiospores. These species failed to assimilate esculin, whereas A. elegans was able to assimilate that glycoside. Amphotericin B and posaconazole are the most active in vitro drugs against Apophysomyces.

Less-frequent Fusarium species of clinical interest: correlation between morphological and molecular identification and antifungal susceptibility.

Forty-eight Fusarium isolates morphologically identified as belonging to seven species of clinical interest (i.e., Fusarium chlamydosporum, Fusarium dimerum, Fusarium incarnatum, Fusarium napiforme, Fusarium nygamai, Fusarium proliferatum, and Fusarium sacchari) were characterized molecularly by the analysis of the sequences of the TUB region of the beta-tubulin gene. F. chlamydosporum and F. dimerum were the most genetically heterogeneous species. A high degree of correlation between the morphological and molecular identification was shown among the isolates studied. A table with the key morphological features for the identification of these Fusarium species is provided. The antifungal susceptibilities of the Fusarium isolates to 11 antifungal drugs were tested; terbinafine was the most active drug against all the species tested with the exception of F. incarnatum, for which amphotericin B was the most active.