RESUMEN
The epidemiology of invasive fungal disease (IFD) due to filamentous fungi other than Aspergillus may be changing. We analysed clinical, microbiological and outcome data in Australian patients to determine the predisposing factors and identify determinants of mortality. Proven and probable non-Aspergillus mould infections (defined according to modified European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria) from 2004 to 2012 were evaluated in a multicentre study. Variables associated with infection and mortality were determined. Of 162 episodes of non-Aspergillus IFD, 145 (89.5%) were proven infections and 17 (10.5%) were probable infections. The pathogens included 29 fungal species/species complexes; mucormycetes (45.7%) and Scedosporium species (33.3%) were most common. The commonest comorbidities were haematological malignancies (HMs) (46.3%) diabetes mellitus (23.5%), and chronic pulmonary disease (16%); antecedent trauma was present in 21% of cases. Twenty-five (15.4%) patients had no immunocompromised status or comorbidity, and were more likely to have acquired infection following major trauma (p <0.01); 61 (37.7%) of cases affected patients without HMs or transplantation. Antifungal therapy was administered to 93.2% of patients (median 68 days, interquartile range 19-275), and adjunctive surgery was performed in 58.6%. The all-cause 90-day mortality was 44.4%; HMs and intensive-care admission were the strongest predictors of death (both p <0.001). Survival varied by fungal group, with the risk of death being significantly lower in patients with dematiaceous mould infections than in patients with other non-Aspergillus mould infections. Non-Aspergillus IFD affected diverse patient groups, including non-immunocompromised hosts and those outside traditional risk groups; therefore, definitions of IFD in these patients are required. Given the high mortality, increased recognition of infections and accurate identification of the causative agent are required.
Asunto(s)
Fungemia/epidemiología , Fungemia/microbiología , Hongos/clasificación , Hongos/aislamiento & purificación , Meningitis Fúngica/epidemiología , Meningitis Fúngica/microbiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antifúngicos , Australia/epidemiología , Niño , Comorbilidad , Fungemia/mortalidad , Fungemia/terapia , Humanos , Masculino , Meningitis Fúngica/mortalidad , Meningitis Fúngica/terapia , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Procedimientos Quirúrgicos Operativos , Análisis de Supervivencia , Adulto JovenRESUMEN
Complex syringomyelia is multifactorial, and treatment strategies are highly individualized. In refractory cases, sectioning of the filum terminale, also known as terminal ventriculostomy, has been described as a potential adjuvant treatment to alleviate syrinx progression. A 10-year-old boy with a history of arachnoiditis presented with complex syringomyelia, progressive lower extremity motor weakness, and spasticity. Previously, he had failed spinal cord detethering and direct syrinx shunting. Imaging studies demonstrated a holocord syrinx extending to the level of his conus medullaris and into the filum terminale. The patient underwent an uncomplicated lumbar laminectomy and transection of the filum terminale. Operative pathologic specimens demonstrated a dilated central canal within the filum. Postoperative imaging demonstrated significant reduction in the diameter of the syrinx. At follow-up, the patient's motor symptoms had improved. Terminal ventriculostomy may be a useful adjuvant in treating caudally placed syringes refractory to other treatments. This procedure carries low neurological risk and involves no hardware implantation. In select cases, terminal ventriculostomy may help preserve neurological function in the face of otherwise progressive syringomyelia.
Asunto(s)
Cauda Equina/patología , Cauda Equina/cirugía , Siringomielia/patología , Siringomielia/cirugía , Ventriculostomía/métodos , Aracnoiditis/complicaciones , Aracnoiditis/cirugía , Aracnoiditis/terapia , Niño , Humanos , Masculino , Meningitis Fúngica/complicaciones , Meningitis Fúngica/cirugía , Meningitis Fúngica/terapia , Defectos del Tubo Neural/etiología , Defectos del Tubo Neural/cirugía , Defectos del Tubo Neural/terapia , Siringomielia/terapiaRESUMEN
Young diabetics can sometimes have difficulty with insulin compliance for various reasons. This can be exacerbated if associated with body dysmorphic disorder or other eating disorders. The manipulation of insulin to lose weight can have devastating consequences. The authors describe a fatal case of rhino-orbital-cerebral mucormycosis secondary to insulin manipulation for the purpose of weight loss.
Asunto(s)
Trastorno Dismórfico Corporal/complicaciones , Infecciones Fúngicas del Ojo/etiología , Meningitis Fúngica/etiología , Mucormicosis/etiología , Enfermedades Orbitales/microbiología , Enfermedades de los Senos Paranasales/microbiología , Adolescente , Trastorno Dismórfico Corporal/diagnóstico , Trastorno Dismórfico Corporal/terapia , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/etiología , Cetoacidosis Diabética/etiología , Infecciones Fúngicas del Ojo/diagnóstico , Infecciones Fúngicas del Ojo/terapia , Resultado Fatal , Femenino , Humanos , Insulina/administración & dosificación , Angiografía por Resonancia Magnética , Meningitis Fúngica/diagnóstico , Meningitis Fúngica/terapia , Mucormicosis/diagnóstico , Mucormicosis/terapia , Enfermedades Orbitales/diagnóstico , Enfermedades Orbitales/terapia , Enfermedades de los Senos Paranasales/diagnóstico , Enfermedades de los Senos Paranasales/terapiaRESUMEN
The syndrome of inappropriate antidiuretic hormone (SIADH) secretion has been well described in patients with meningeal spread from metastatic carcinomatosis and bacterial or mycobacterial infections. We describe a 39-year-old white man who was diagnosed with coccidioidomycosis pneumonia 7 years before presentation. He displayed evidence for meningitis with the onset of SIADH. We reviewed the diagnosis of coccidioidomycosis and radiological findings in the central nervous system. Last, we discussed the findings that led to the diagnosis of SIADH.
Asunto(s)
Coccidioides , Síndrome de Secreción Inadecuada de ADH/complicaciones , Meningitis Fúngica/complicaciones , Vasopresinas/metabolismo , Adulto , Humanos , Síndrome de Secreción Inadecuada de ADH/diagnóstico , Imagen por Resonancia Magnética , Masculino , Meningitis Fúngica/diagnóstico , Meningitis Fúngica/terapiaRESUMEN
BACKGROUND: Rhino-orbito-cerebral mucormycosis (ROCM) is a devastating infection of immunocompromised hosts. We present our experience with 19 ROCM cases and attempt to define preferred diagnostic and treatment protocols. METHODS: All had tissue biopsies obtained studied by direct smear, histologic studies, and cultures. Imaging was obtained in 14 cases. RESULTS: Sixteen patients presented between August and November. Six had mixed fungal infections. Seven patients had end-stage underlying disease or infection and did not undergo surgery and 4 had an indolent form of disease. Patients were treated by surgery and by amphotericin B. The overall survival was 47%. CONCLUSIONS: ROCM may have seasonal incidence peaking in the fall and early winter. The therapeutic approach should be unchanged in cases of mixed fungal infections. Amphotericin B with aggressive debridement remains the mainstay of treatment. Early recognition and treatment are essential. A presentation and survival-dependent classification of ROCM are offered.
Asunto(s)
Infecciones Fúngicas del Ojo/terapia , Meningitis Fúngica/terapia , Mucormicosis/diagnóstico , Mucormicosis/terapia , Enfermedades Nasales/terapia , Infecciones Oportunistas/microbiología , Infecciones Oportunistas/terapia , Adulto , Anciano , Anciano de 80 o más Años , Antifúngicos/administración & dosificación , Terapia Combinada , Desbridamiento/métodos , Infecciones Fúngicas del Ojo/microbiología , Infecciones Fúngicas del Ojo/mortalidad , Femenino , Humanos , Huésped Inmunocomprometido , Masculino , Meningitis Fúngica/microbiología , Meningitis Fúngica/mortalidad , Persona de Mediana Edad , Mucormicosis/mortalidad , Enfermedades Nasales/microbiología , Enfermedades Nasales/mortalidad , Infecciones Oportunistas/mortalidad , Pronóstico , Medición de Riesgo , Muestreo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Vasculitis complicating coccidioidal meningitis is becoming increasingly recognized. At this time, predisposing clinical features have not been elucidated. Histologically, 2 types of vascular inflammation have been described. The first is a transmural inflammatory process of the intracranial blood vessels that occurs early in the course of disease. Encroachment of the vessel lumen may result in thrombosis. The second process occurs with chronic disease and is associated with intimal thickening and luminal occlusion with little inflammation. Numerous substances, including metalloproteinases, cytokines such as tumor necrosis factor (TNF)-alpha, and an elastase, have been postulated as putative virulence factors. Recently, a rabbit model has been developed that appears to closely mimic human disease. By using this model, a parallel between coccidioidal vasculitis and temporal arteritis has been developed. Currently, there are no established therapies for coccidioidal vasculitis. The use of corticosteroids is controversial. Of interest are agents that may block the pathologic process, such as omega-3 oils, and pentoxyfylline.
Asunto(s)
Coccidioidomicosis/complicaciones , Coccidioidomicosis/patología , Meningitis Fúngica/complicaciones , Meningitis Fúngica/patología , Vasculitis/etiología , Vasculitis/patología , Animales , Coccidioidomicosis/terapia , Modelos Animales de Enfermedad , Humanos , Meningitis Fúngica/terapia , Conejos , Vasculitis/terapiaRESUMEN
We present a case of disseminated intracranial infection by Candida albicans in a 5-year-old girl who had fever and a change of consciousness after surgery for complex congenital heart malformation. MR imaging revealed multiple small ring-enhancing hemorrhagic abscesses. One year after antifungal treatment, the abscesses and ventriculomegaly were almost completely resolved. The patient was discharged in a stable but vegetative condition.
Asunto(s)
Candidiasis/diagnóstico , Meningitis Fúngica/diagnóstico , Infecciones Oportunistas/diagnóstico , Anfotericina B/administración & dosificación , Antifúngicos/administración & dosificación , Encéfalo/patología , Candidiasis/terapia , Preescolar , Terapia Combinada , Quimioterapia Combinada , Femenino , Fluconazol/administración & dosificación , Cardiopatías Congénitas/cirugía , Humanos , Hidrocefalia/diagnóstico , Hidrocefalia/terapia , Meningitis Fúngica/terapia , Infecciones Oportunistas/terapia , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/terapia , Derivación VentriculoperitonealRESUMEN
BACKGROUND: Infection with Cryptococcus neoformans is common in the Northern Territory of Australia. Disease is life threatening and treatment is prolonged and often complicated by the need for surgery and difficulties with medical therapy. AIMS: To document incidence, demography, risk factors, clinical features and outcomes of infection and to determine differences between gattii and neoformans varieties. METHODS: Case records of all patients (n = 35) diagnosed with cryptococcal infection at the Royal Darwin Hospital between 1976 and 1992 were reviewed retrospectively. Current status of patients was ascertained. Variety identification of isolates was determined by growth in canavanine-glycine-bromthymol blue agar. RESULTS: Of the 35 patients, 23 had meningitis, ten had pneumonia, one had a dermal infection and one had fungaemia with no obvious focus. Twelve (52%) meningitis cases and two (20%) pneumonia cases had no predisposing disease. Thirteen (57%) meningitis cases had concomitant pulmonary cryptococcosis. Twenty-nine patients with Aboriginal and six were Caucasian, with a relative risk for Aboriginals compared with non-Aboriginals of 20.6 (95% CI 8.6-49.5). Arnhemland was the commonest location of infection, with an annual incidence in Aboriginals of 0.14/1000. Fourteen (78%) of 18 isolates tested were C. neoformans var. gattii. Management was characterised by the frequent need for adjunctive surgery and prolonged or repeat courses of systemic antifungal therapy. Despite this, long-term outcomes are encouraging with a mortality of 14% overall and 9% in meningitis patients. The river red gum (Eucalyptus camaldulensis) has a limited distribution in Arnhemland and ongoing studies are seeking alternative environmental sources of C. neoformans var. gattii.