Risks and features of secondary infections in severe and critical ill COVID-19 patients.

Objectives Severe or critical COVID-19 is associated with intensive care unit admission, increased secondary infection rate, and would lead to significant worsened prognosis. Risks and characteristics relating to secondary infections in severe COVID-19 have not been described. Methods Severe and critical COVID-19 patients from Shanghai were included. We collected lower respiratory, urine, catheters, and blood samples according to clinical necessity and culture and mNGS were performed. Clinical and laboratory data were archived. Results We found 57.89% (22/38) patients developed secondary infections. The patient receiving invasive mechanical ventilation or in critical state has a higher chance of secondary infections (P<0.0001). The most common infections were respiratory, blood-stream and urinary infections, and in respiratory infections, the most detected pathogens were gram-negative bacteria (26, 50.00%), following by gram-positive bacteria (14, 26.92%), virus (6, 11.54%), fungi (4, 7.69%), and others (2, 3.85%). Respiratory Infection rate post high flow, tracheal intubation, and tracheotomy were 12.90% (4/31), 30.43% (7/23), and 92.31% (12/13) respectively. Secondary infections would lead to lower discharge rate and higher mortality rate. Conclusion Our study originally illustrated secondary infection proportion in severe and critical COVID-19 patients. Culture accompanied with metagenomics sequencing increased pathogen diagnostic rate. Secondary infections risks increased after receiving invasive respiratory ventilations and intravascular devices, and would lead to a lower discharge rate and a higher mortality rate.

Bloodstream Infection of a Cancer Patient by Cystobasidium minutum: A Case Report and Literature Review.

Emergent fungal infections are uncommon conditions which frequently lead to death. To our knowledge, only a few cases of invasive infection by Cystobasidium minutum (previously known as Rhodotorula minuta) have been reported. Moreover, several factors are responsible for deep site infections, such as catheter-related fungemia. This report describes the first case report of Cystobasidium minutum causing fungemia in Brazil. The pathogens fungemia was demonstrated by catheter and blood culture-proven, and both yeasts were identified by sequences of D1/D2 rDNA region. After the end of antifungal therapy and catheter removal, a second blood culture was found to be negative and the clinical signs and symptoms of the patient improved.

Fatal Disseminated Infection by Trichosporon asahii Under Voriconazole Therapy in a Patient with Acute Myeloid Leukemia: A Review of Breakthrough Infections by Trichosporon spp.

INTRODUCTION: Cases of invasive Trichosporon infections have increasingly emerged; it is now the second leading cause of yeast bloodstream infections after Candida spp., particularly in the immunosuppressed population, where it often causes breakthrough fungemia with high mortality. METHODS: We present a case report of a breakthrough Trichosporon asahii infection in a patient with acute myeloid leukemia and review all of the cases of breakthrough Trichosporon spp. infections published in the literature to date. RESULTS: We extracted 68 cases of breakthrough Trichosporon spp. infections, wherein 95.5% patients had hematological malignancy, 61.8% of them occurred in the presence of echinocandins, 22% of triazoles, 13.2% of amphotericin and 3% of other combinations of antifungals. The most prevalent manifestation was fungemia (94%); 82.8% of these were associated with the presence of a central venous catheter. The overall mortality was 68.7%; the patients who survived recovered from the neutropenic event. CONCLUSIONS: Invasive trichosporonosis is an acute fatal condition that occurs in immunosuppressed patients, usually under antifungal selective pressure. Typically, neutropenia and its underlying diseases are associated with adverse outcomes.

Persistent hematogenous dissemination in pulmonary P. jiroveci infection.

Pneumocystis jiroveci pneumonia in non-HIV patients is infrequent and characterized by atypical presentations and increased severity. Although hematogenous dissemination from the lungs can lead to extrapulmonary infections, isolation of oocysts from blood in human subjects has not been documented. We report a case of P. jiroveci pneumonia with persistent isolation of oocysts from blood and positivity of P. jiroveci polymerase chain reaction. The patient presented with bilateral diffuse pulmonary nodules and received prolonged treatment with trimethoprim/sulfamethoxazole.

Eremothecium coryli bloodstream infection in a patient with acute myeloid leukemia: first case report of human infection.

Eremothecium coryli is a dimorphic fungus of the Saccharomycetes class. While species within this class are known to cause human infection, Eremothecium species have previously only been known as phytopathogens and never been isolated from a human sample. Here, we report the first known case of human E. coryli infection.

Impact of matrix-assisted laser desorption/ionization time of flight mass spectrometric evaluation on the clinical outcomes of patients with bacteremia and fungemia in clinical settings lacking an antimicrobial stewardship program: a pre-post quasi experimental study.

BACKGROUNDS: Several studies have evaluated the impact of matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) combined with antimicrobial stewardship in patients with positive blood cultures; clinical outcomes improved. However, in many hospitals, antimicrobial stewardship is not available because of restricted medical resources. Thus, we investigated the impact of evaluation by MALDI-TOF MS on the clinical outcomes of patients with bacteremia and fungemia treated in a clinical setting lacking an antimicrobial stewardship program (ASP). METHODS: We designed a pre-post quasi experimental study and retrospectively reviewed the medical records of patients aged > 18 years old with bacteremia and fungemia during two periods: October-December 2012 and October-December 2013. Conventional methods were used to detect microbial pathogens in 2012, and MALDI-TOF MS was employed in 2013. Clinical outcomes compared between periods were the time to pathogen identification, time to effective therapy, 30-day all-cause mortality, time to microbiological clearance, length of ICU stay, and rate of recurrence of the same bloodstream infection (BSI). RESULTS: A total of 556 patients were enrolled; 302 patients in 2012, and 254 in 2013. The use of MALDI-TOF MS without an ASP reduced the time to pathogen identification (86.4 vs. 63.5 h, P < 0.001) but did not significantly reduce the time to effective therapy (27.4 vs. 23.2 h, P = 0.187). Also, none of the following differed significantly between the two periods: mortality (17.5 vs. 15.7%, P = 0.571), the time to microbiological clearance (3.6 vs. 3.7 days, P = 0.675), the length of ICU stay (16.8 vs. 14.7 days, P = 0.706), and the recurrence rate of the same BSI (5.0 vs. 2.8%, P = 0.183). CONCLUSIONS: The use of MALDI-TOF MS alone in a setting lacking an ASP did not afford clinical benefits. An ASP combined with MALDI-TOF MS is necessary to improve clinical outcomes.

Cryptococcus laurentii fungemia in a low birth weight preterm neonate: India.

In the last few years, Cryptococcus laurentii infections have increased, particularly in immunocompromised patients. Here we report the first case of C. laurentii fungemia in low birth weight preterm infant from India. A preterm neonate was admitted for feeding intolerance and respiratory distress. Blood culture ascertained the causative organism as C. laurentii. The isolated strain was found susceptible to amphotericin B and the patient recovered following the administration of amphotericin B (5mg/kg body weight) for 8days.

[Clinical problems in medical mycology: Problem number 51]. / Problemas clínicos en micología médica: problema número 51.

A 48 year-old immunocompetent woman, who had a nodular lesion in the neck and a dense infiltrate at the lower lobe of the left lung, presented at the Mycology Unit of Muñiz Hospital of Buenos Aires City. The pulmonary infiltrate disappeared spontaneously 3 months later. The histopathological study of the nodular lesion showed capsulated yeasts (mucicarmin and alcian blue positive stains) compatible with Cryptococcus. The mycological study of a new sample, obtained by a nodular puncture, allowed the isolation of yeasts, identified as Cryptococcus gattii (VGII). Latex test for Cryptococcus capsular antigen in serum was positive (1/100). CSF cultures rendered negative results. Fluconazole at a daily dose of 800mg was given during 45 days with partial improvement; as cultures from a new clinical sample were positive for Cryptococcus, the antimycotic was changed to itraconazole 400mg/day for 5 months, with an excellent clinical response.

[Role of surgery in Saprochaete capitata (S. capitata) sepsis in a patient with acute myeloid leukemia]. / Rol de la cirugía en el manejo de la infección invasora por Saprochaete capitata.

Saprochaete capitata (S. capitata) fungal sepsis is a severe condition with a clinical presentation that is similar to other yeast originated fungal sepsis. It is observed in patients with hematological malignancies such as acute myeloid leukemia and neutropenia. We report a 23 year old male presenting with cough, fever and malaise. A bone marrow biopsy led to the diagnosis of acute myeloid leukemia. During the first cycle of chemotherapy the patient presented fever: blood cultures were positive for Klebsiella pneumoniae. Despite antimicrobial treatment, fever persisted; a computed tomography showed a focal splenic lesion; a left exudative pleural effusion appeared. A Matrix Assisted Laser Desorption Ionization-Time of Flight mass spectrometry identified the presence of S. capitata. After multiple antifungal treatments and pleural cavity cleansing by means of videothoracoscopy and laparoscopic splenectomy, the infection resolved and the patient completed his chemotherapy.

Rol de la cirugía en el manejo de la infección invasora por Saprochaete capitata / Role of surgery in Saprochaete capitata (S. capitata) sepsis in a patient with acute myeloid leukemia

Saprochaete capitata (S. capitata) fungal sepsis is a severe condition with a clinical presentation that is similar to other yeast originated fungal sepsis. It is observed in patients with hematological malignancies such as acute myeloid leukemia and neutropenia. We report a 23 year old male presenting with cough, fever and malaise. A bone marrow biopsy led to the diagnosis of acute myeloid leukemia. During the first cycle of chemotherapy the patient presented fever: blood cultures were positive for Klebsiella pneumoniae. Despite antimicrobial treatment, fever persisted; a computed tomography showed a focal splenic lesion; a left exudative pleural effusion appeared. A Matrix Assisted Laser Desorption Ionization-Time of Flight mass spectrometry identified the presence of S. capitata. After multiple antifungal treatments and pleural cavity cleansing by means of videothoracoscopy and laparoscopic splenectomy, the infection resolved and the patient completed his chemotherapy.

Fungemia and necrotic lymph node infection with Sporopachydermia cereana in a patient with acute myeloid leukemia.

Sporopachydermia cereana is a rare yeast found in necrotic cactus tissue, predominantly in the Americas. Infection in humans with clinical data has only been reported in four patients so far, all of whom died, either directly from the pathogen or from other complications of immunosuppression. Treatment of the yeast is complicated by difficulties in identification of the pathogen with conventional diagnostic techniques and by intrinsic resistance to echinocandins. The first patient to survive a disseminated infection with S. cereana is presented herein. The patient had acute myeloid leukemia and was treated successfully with antifungal therapy and subsequently underwent a successful allogeneic hematopoietic stem cell transplantation.

Paecilomyces variotii Fungemia in a Patient with Lymphoma Needing Liver Transplant.

Paecilomyces sp. are emerging pathogens in immunocompromised patients. We report here a case of Paecilomyces variotii fungemia, cured with amphotericin and anidulafungin, illustrating difficulties of early diagnosis and therapeutic choice in such rare fungal infection.

Fungemia due to Saprochaete capitata in a non-neutropenic patient hospitalized in an intensive care unit after cardiac surgery.

The majority of invasive fungal infections observed in non-neutropenic patients hospitalized in an intensive care unit are caused by Candida spp and current guidelines recommend echinocandins as the first-line treatment. Fungemias caused by filamentous or arthrosporic fungi such as Saprochaete capitata (previously named Geotrichum capitatum) are extremely rare. In fact, invasive infections due to S. capitata have been reported almost exclusively in neutropenic oncohematological patients. In this report, we describe a case of fungemia caused by S. capitata in a non-neutropenic patient hospitalized in an intensive care unit after aortic valve replacement. The prompt identification of S. capitata is extremely important because of its intrinsic resistance to echinocandins.

Acute Disseminated Talaromyces marneffei in An Immunocompetent Patient.

Talaromyces marneffei (also called Penicilliosis Marneffei or T. marneffei) is a rare fungal disease that is prevalent mainly in Southeast Asia and commonly seen in immunocompromised hosts. It was rarely observed in immunocompetent hosts. We report a case of acute disseminated T. marneffei in an immunocompetent patient in the non-prevalent region. This patient had never visited the endemic area. The patient experienced a persistent fever. Brain CT and magnetic resonance imaging (MRI) showed a mass in the right frontal with osteolytic damage. Excessive white blood cell (WBC) count and C-reactive protein content were observed. Antibiotics including meropenem and linezolid could not play an effect, and another two hard masses appeared in his right neck and front chest wall. The aspirates from the right frontal mass and bone marrow were cultured. The final diagnose of this infection was disseminated T. marneffei. After voriconazole treatment, all symptoms improved gradually. We present this case and aim to promote more clinicians and microbiologists in the non-endemic region to recognize this rare disease.

Unique characteristics of cryptococcosis identified after death in patients with liver cirrhosis: comparison with concurrent cohort diagnosed antemortem.

Characteristics of cirrhosis-associated cryptococcosis first diagnosed after death are not fully known. In a multicenter study, data generated as standard of care was systematically collected in 113 consecutive patients with cirrhosis and cryptococcosis followed for 80 patient-years. The diagnosis of cryptococcosis was first established after death in 15.9% (18/113) of the patients. Compared to cases diagnosed while alive, these patients had higher MELD score (33 vs. 22, P = .029) and higher rate of cryptococcemia (75.0% vs. 41.9%, P = .027). Cases diagnosed after death, in comparison to those diagnosed during life were more likely to present with shock (OR 3.42, 95% CI 1.18-9.90, P = .023), require mechanical ventilation at admission (OR 8.5, 95% CI 2.74-26.38, P = .001), less likely to undergo testing for serum cryptococcal antigen (OR 0.07, 95% CI 0.02-0.21, P < .001) and have positive antigen when the test was performed (OR 0.07, 95% CI 0.01-0.60, P = .016). In a subset of cirrhotic patients with advanced liver disease cryptococcosis was first recognized after death. These patients had the characteristics of presenting with fulminant fungemia, were less likely to have positive serum cryptococcal antigen and posed a diagnostic challenge for care providers.

Trichosporon loubieri Fungemia in a 39-Year-Old Caucasian Woman With B-Cell Lymphoblastic Leukemia.

We report a case of Trichosporon loubieri (T. loubieri) fungemia with likely liver involvement in a 39-year-old Caucasian patient with relapsed B-cell acute lymphoblastic leukemia after an allogeneic hematopoietic cell transplant. This is the fifth published case of T. loubieri infection and only the third case of T. loubieri fungemia, to our knowledge. All 3 cases of T. loubieri infection with fungemia had liver involvement.

The Simultaneous Occurrence of Histoplasmosis and Cryptococcal Fungemia: A Case Report and Review of the Literature.

Simultaneous infections with Cryptococcus neoformans and Histoplasma capsulatum are rare and typically occur in immunocompromised individuals, particularly AIDS patients. Because both of those fungi can spur the development of latent infections, it is generally unknown which organism was first present. The diagnosis of one fungus can hide the diagnosis of the other, leading to underdiagnoses and poor prognosis. We report a case of C. neoformans and H. capsulatum co-infection. We also performed a systematic review of the literature. Our patient, a 69-year-old HIV-negative man, presented with a 9-month history of a productive cough, dyspnea and wheezing. His history showed chronic obstructive pulmonary disease and type II diabetes mellitus (DM). Pulmonary lesions of unidentified etiology were noted. Cryptococcal involvement of the central nervous system was confirmed, and C. neoformans and H. capsulatum were also isolated from blood cultures. In the literature, we found ten cases of simultaneous histoplasmosis and cryptococcosis. Including our patient, all of the cases were located in North America and Latin America, except for two, one Indian and one African diagnosed in France. AIDS was the main predisposing factor, followed by DM and age >60 years. Several diagnostic methods were employed. A blood culture and bronchoalveolar lavage (BAL) culture resulted in the growth of C. neoformans in most of the cases. H. capsulatum was more often detected in BAL and bone marrow cultures. Although co-infection by these pathogens is severe, it can be cured if it is diagnosed and treated early. We emphasized the importance of clinical suspicion and differential diagnosis of systemic mycoses.

Cryptococcosis in non-HIV/non-transplant patients: A Brazilian case series.

Cryptococcosis is a classical systemic opportunistic mycosis, primarily occurring among patients with significant immunologic impairment. However, this disease could also affect patients without any recognized immunologic defects, that is, phenotypically normal patients. The medical records of 29 non-HIV/nontransplant patients with cryptococcal disease during the period 2007-2014 were retrospectively reviewed. The most common site of infection was the central nervous system (n = 25, 86.2%), followed by the pulmonary system (n = 11, 37.9%) and blood (n = 2, 6.8%). Thoracic- and brain-computed tomography demonstrated abnormalities of 81.2% (n = 13) and 62.5% (n = 15), respectively. In sum, 22% (n = 6) of the patients experienced a significant underlying condition. More than one therapeutic regimen was used in 77.8% (n = 21) of the patients. The isolates were identified as being Cryptococcus neoformans species complex (n = 4, 36.4%) and Cryptococcus gattii species complex (n = 7, 63.6%). The overall mortality was 20.7% (n = 6). Herein, we presented the first case series of cryptococcosis in this specific population in São Paulo City, Brazil. The incidence of cryptococcosis in our hospital has not increased in recent years, and 77.8% (n = 21) of cases had no obvious predisposing factor. However, this disease remains associated with high mortality.

Characteristics and risk factors for 28-day mortality of hospital acquired fungemias in ICUs: data from the EUROBACT study.

BACKGROUND: To characterize and identify prognostic factors for 28-day mortality among patients with hospital-acquired fungemia (HAF) in the Intensive Care Unit (ICU). METHODS: A sub-analysis of a prospective, multicenter non-representative cohort study conducted in 162 ICUs in 24 countries. RESULTS: Of the 1156 patients with hospital-acquired bloodstream infections (HA-BSI) included in the EUROBACT study, 96 patients had a HAF. Median time to its diagnosis was 20 days (IQR 10.5-30.5) and 9 days (IQR 3-15.5) after hospital and ICU admission, respectively. Median time to positivity of blood culture was longer in fungemia than in bacteremia (48.7 h vs. 38.1 h; p = 0.0004). Candida albicans was the most frequent fungus isolated (57.1%), followed by Candida glabrata (15.3%) and Candida parapsilosis (10.2%). No clear source of HAF was detected in 33.3% of the episodes and it was catheter-related in 21.9% of them. Compared to patients with bacteremia, HAF patients had a higher rate of septic shock (39.6% vs. 21.6%; p = 0.0003) and renal dysfunction (25% vs. 12.4%; p = 0.0023) on admission and a higher rate of renal failure (26% vs. 16.2%; p = 0.0273) at diagnosis. Adequate treatment started within 24 h after blood culture collection was less frequent in HAF patients (22.9% vs. 55.3%; p < 0.001). The 28-day all cause fatality was 40.6%. According to multivariate analysis, only liver failure (OR 14.35; 95% CI 1.17-175.6; p = 0.037), need for mechanical ventilation (OR 8.86; 95% CI 1.2-65.24; p = 0.032) and ICU admission for medical reason (OR 3.87; 95% CI 1.25-11.99; p = 0.020) were independent predictors of 28-day mortality in HAF patients. CONCLUSIONS: Fungi are an important cause of hospital-acquired BSI in the ICU. Patients with HAF present more frequently with septic shock and renal dysfunction on ICU admission and have a higher rate of renal failure at diagnosis. HAF are associated with a significant 28-day mortality rate (40%), but delayed adequate antifungal therapy was not an independent risk factor for death. Liver failure, need for mechanical ventilation and ICU admission for medical reason were the only independent predictors of 28-day mortality.

Catheter-Related Bloodstream Infection Due to Lodderomyces elongisporus.

Lodderomyces elongisporus infrequently causes bloodstream infections and has been isolated from Asia and Mexico. We encountered a catheter-related bloodstream infection, which involved some risk factors, due to L. elongisporus masquerading as Candida parapsilosis. A 39-year-old man who received a total arch and thoracoabdominal aortic replacement was admitted with a diagnosis of aorto-esophageal fistula. After thoracic drainage for the aorto-esophageal fistula, a catheter-related bloodstream infection was diagnosed. Micafungin (100 mg/day) was successfully administered to treat the catheter-related bloodstream infection for 42 days in total. The bloodstream and catheter tip yeast was grown on Candida agar medium and produced dark green colonies indicating Candida albicans. We performed sequencing analysis using a GenBank BLAST search. The sequence of the internal transcribed spacer region was 99.9% identical with that of the type strain L. elongisporus. This yeast organism has frequently been technically mistaken for non-albicans Candida spp. Furthermore, the prognosis and risk factors of L. elongisporus infection remain unclear owing to the scarcity of reported cases. Catheter-related bloodstream infection caused by this organism has not been described to date.