Liver abscess caused by Candida haemulonii var. vulnera. First case report in Peru.

BACKGROUND: Liver abscesses caused by Candida species are mainly found in immunocompromised hosts, associated with conditions (such as neutropenia and mucositis) that facilitate the spreading of microorganisms from the gastrointestinal tract. CASE REPORT: We present the case of a non-immunocompromised 72-year-old woman with a liver abscess caused by Candida haemulonii var. vulnera, in whom potential associated conditions could be polycystic kidney disease and renal replacement therapy. The patient experienced clinical resolution after percutaneous drainage and treatment with caspofungin. CONCLUSIONS: To our knowledge, this is the first case reported in Peru of a liver abscess due to Candida haemulonii var. vulnera, a clinical presentation that has not been described previously. This finding should prompt us to establish active surveillance of causal agents of systemic candidiasis.

The Diagnosis of Fungal Neglected Tropical Diseases (Fungal NTDs) and the Role of Investigation and Laboratory Tests: An Expert Consensus Report.

The diagnosis of fungal Neglected Tropical Diseases (NTD) is primarily based on initial visual recognition of a suspected case followed by confirmatory laboratory testing, which is often limited to specialized facilities. Although molecular and serodiagnostic tools have advanced, a substantial gap remains between the desirable and the practical in endemic settings. To explore this issue further, we conducted a survey of subject matter experts on the optimal diagnostic methods sufficient to initiate treatment in well-equipped versus basic healthcare settings, as well as optimal sampling methods, for three fungal NTDs: mycetoma, chromoblastomycosis, and sporotrichosis. A survey of 23 centres found consensus on the key role of semi-invasive sampling methods such as biopsy diagnosis as compared with swabs or impression smears, and on the importance of histopathology, direct microscopy, and culture for mycetoma and chromoblastomycosis confirmation in well-equipped laboratories. In basic healthcare settings, direct microscopy combined with clinical signs were reported to be the most useful diagnostic indicators to prompt referral for treatment. The survey identified that the diagnosis of sporotrichosis is the most problematic with poor sensitivity across the most widely available laboratory tests except fungal culture, highlighting the need to improve mycological diagnostic capacity and to develop innovative diagnostic solutions. Fungal microscopy and culture are now recognized as WHO essential diagnostic tests and better training in their application will help improve the situation. For mycetoma and sporotrichosis, in particular, advances in identifying specific marker antigens or genomic sequences may pave the way for new laboratory-based or point-of-care tests, although this is a formidable task given the large number of different organisms that can cause fungal NTDs.

[Invasive Fusariosis: Report of Three Cases in Peru]. / Fusariosis invasiva: reporte de tres casos en Perú.

Fusarium species are a group of fungi that cause superficial infections, locally invasive and disseminated disease, which occur mainly in immunocompromised hosts, and occasionally in immunocompetent individuals. We present three cases that show three different clinical forms of Fusarium spp. disease that affected different types of patients (patients with hematological malignancy, chronic kidney disease in peritoneal dialysis and post-surgical for osteoarticular pathology), each with its own characteristics that merit discussion. These cases show different clinical forms of invasive fusariosis caused by Fusarium solani complex species in patients with different pathologies and therapeutic management that could be risk factors for the development of the disease. The clinical recognition of fusariosis, not only in oncohematological patients, together with a timely diagnosis and treatment contribute to the success of the treatment and a reduction in mortality.

Las especies de Fusarium son un grupo de hongos que causan infecciones superficiales, localmente invasivas y enfermedad diseminada, que ocurren principalmente en huéspedes inmunocomprometidos, y ocasionalmente en individuos inmunocompetentes. Presentamos tres casos que ponen en manifiesto tres diferentes formas clínicas de la enfermedad por Fusarium spp., que afectaron diversos tipos de pacientes (pacientes con malignidad hematológica, enfermedad renal crónica en diálisis peritoneal y post-quirúrgico por patología osteoarticular), cada una con características propias que ameritan su discusión. Estos casos ponen de manifiesto diferentes formas clínicas de fusariosis invasiva causadas por especies del complejo Fusarium solani en pacientes con diferentes patologías y manejo terapéutico que podrían ser factores de riesgo para el desarrollo de la enfermedad. El reconocimiento clínico de la Fusariosis, no solo en pacientes oncohematólogicos, junto con un diagnóstico y tratamiento oportuno contribuyen al éxito del tratamiento y a una reducción en la mortalidad.

Fusariosis invasiva: reporte de tres casos en Perú / Invasive Fusariosis: Report of Three Cases in Peru

RESUMEN Las especies de Fusarium son un grupo de hongos que causan infecciones superficiales, localmente invasivas y enfermedad diseminada, que ocurren principalmente en huéspedes inmunocomprometidos, y ocasionalmente en individuos inmunocompetentes. Presentamos tres casos que ponen en manifiesto tres diferentes formas clínicas de la enfermedad por Fusarium spp., que afectaron diversos tipos de pacientes (pacientes con malignidad hematológica, enfermedad renal crónica en diálisis peritoneal y post-quirúrgico por patología osteoarticular), cada una con características propias que ameritan su discusión. Estos casos ponen de manifiesto diferentes formas clínicas de fusariosis invasiva causadas por especies del complejo Fusarium solani en pacientes con diferentes patologías y manejo terapéutico que podrían ser factores de riesgo para el desarrollo de la enfermedad. El reconocimiento clínico de la Fusariosis, no solo en pacientes oncohematólogicos, junto con un diagnóstico y tratamiento oportuno contribuyen al éxito del tratamiento y a una reducción en la mortalidad.

ABSTRACT Fusarium species are a group of fungi that cause superficial infections, locally invasive and disseminated disease, which occur mainly in immunocompromised hosts, and occasionally in immunocompetent individuals. We present three cases that show three different clinical forms of Fusarium spp. disease that affected different types of patients (patients with hematological malignancy, chronic kidney disease in peritoneal dialysis and post-surgical for osteoarticular pathology), each with its own characteristics that merit discussion. These cases show different clinical forms of invasive fusariosis caused by Fusarium solani complex species in patients with different pathologies and therapeutic management that could be risk factors for the development of the disease. The clinical recognition of fusariosis, not only in oncohematological patients, together with a timely diagnosis and treatment contribute to the success of the treatment and a reduction in mortality.

A multi-centric Study of Candida bloodstream infection in Lima-Callao, Peru: Species distribution, antifungal resistance and clinical outcomes.

BACKGROUND: The incidence of candidemia is increasing in developing countries. Very little is known about the epidemiology of candidemia in Peru. The aim of this study is to describe the incidence, microbiology, clinical presentation and outcomes of Candida bloodstream infections in three Lima-Callao hospitals. METHODS: Candida spp. isolates were identified prospectively at participant hospitals between November 2013 and January 2015. Susceptibility testing for amphotericin B, fluconazole, posaconazole, voriconazole and anidulafungin was performed using broth microdilution method. Clinical information was obtained from medical records and evaluated. RESULTS: We collected information on 158 isolates and 157 patients. Median age of patients was 55.0 yrs., and 64.1% were males. Thirty-eight (24.2%) episodes of candidemia occurred in those <18 yrs. The frequency of non-Candida albicans was 72.1%. The most frequently recovered species were C. albicans (n = 44, 27.8%), C. parapsilosis (n = 40, 25.3%), C. tropicalis (n = 39, 24.7%) and C. glabrata (n = 15, 9.5%). Only four isolates were resistant to fluconazole, 86.7% (n = 137) were susceptible and 17 were susceptible-dose dependent. Decreased susceptibility to posaconazole was also observed in three isolates, and one to voriconazole. All isolates were susceptible to anidulafungin and amphotericin B. The most commonly associated co-morbid conditions were recent surgery (n = 61, 38.9%), mechanical ventilation (n = 60, 38.2%) and total parenteral nutrition (n = 57, 36.3%). The incidence of candidemia by center ranged between 1.01 and 2.63 cases per 1,000 admissions, with a global incidence of 2.04. Only 28.1% of cases received treatment within 72 hrs. of diagnosis. Overall, the 30-day survival was 60.4% (treated subjects, 67.4%; not-treated patients, 50.9%). CONCLUSIONS: We found a very high proportion of non-albicans Candida species. Despite this, the decreased susceptibility/resistance to fluconazole was only 13.3% and not seen in the other antifungals. Overall, the incidence of candidemia mortality was high when compared to other international studies. It is possible, that the delay in initiating antifungal treatment contributed to the elevated mortality rate, in spite of low antifungal resistance.

Factors associated with early mycological clearance in HIV-associated cryptococcal meningitis.

INTRODUCTION: The first-line combination therapy for HIV-associated cryptococcal meningitis (CM), a condition of high mortality particularly in the first two weeks of treatment, consists of amphotericin B plus flucytosine (5-FC). Given that 5-FC remains unavailable in many countries, the knowledge of factors influencing mycological clearance in patients treated with second-line therapy could contribute to effective management. OBJECTIVES: To determine the factors associated with the clearance of Cryptococcus sp. from the cerebrospinal fluid by the second week of effective antifungal therapy (early mycological clearance) in HIV-associated CM. METHODS: Retrospective cohort study based on secondary data corresponding to HIV-associated CM cases hospitalized at a tertiary health care center in Lima, Peru where 5-FC remains unavailable. Risk factors associated with early mycological clearance were analyzed by generalized linear regression models. RESULTS: From January 2000 to December 2013, 234 individuals were discharged with a diagnosis of HIV-associated CM; in 215 we retrieved the required data. The inpatient mortality was 20% (43/215), 15 of them in the first two weeks of treatment. In the final model (157 cases), adjusted for age, previous episode of CM, ART use, type of antifungal treatment, raised intracranial pressure, frequency of therapeutic lumbar punctures, baseline fungal burden and treatment period, the factors associated with early mycological clearance were: Amphotericin B deoxycholate plus fluconazole as combination therapy (RR, 1.56; 95% CI, 1.14-2.14); severe baseline intracranial pressure (≥35 cm H2O) (RR, 0.57; 95% CI, 0.33-0.99); and baseline fungal burden over 4.5 log10 CFU/mL (RR, 0.61 95% CI: 0.39-0.95). CONCLUSIONS: In a setting without access to first-line therapy for CM, the combination therapy with amphotericin B deoxycholate plus fluconazole was positively associated with early mycological clearance, while high fungal burden and severe baseline intracranial pressure were negatively associated, and thus related to failure.

[Epidemiological clinical and laboratory characterization of sporotrichosis in patients of a tertiary care hospital in Lima, Peru, from 1991 to 2014]. / Caracterización epidemiológica, clínica y de laboratorio de esporotricosis en pacientes de un hospital de tercer nivel en Lima-Perú, entre los años 1991 y 2014.

BACKGROUND: Sporothricosis is endemic in numerous Latin American countries and the rest of the world. In Peru is concentrated in regions with warm and humid climate being little known in the rest of the country. AIM: To describe the epidemiological, clinical and laboratory characteristics of patients diagnosed of sporotrichosis in a tertiary-care level hospital in Lima, Peru from 1991 to 2014. METHODS: This was a retrospective, case series. RESULTS: Ninety four patients were involved; most of them were male adults. This condition was acquired more frequently in Cajamarca, Apurímac, and Amazonas. Fixed and lymphocutaneous form were the most frequent forms of presentation in adults and were mostly distributed in upper limbs. Lesions located in head and neck were most frequent in children. Comorbidities were present in 15% of patients and were more frequent in those who presented disseminated cutaneous form. Seventy eight percent of cultures from skin lesions were positive within 7 days. The time to positivity of cultures was longer if the sample came from skin biopsies than skin scraping or skin aspiration. CONCLUSIONS: Most cases of sporotrichosis were acquired in areas of extreme poverty in Peru. The clinical, epidemiological and laboratory findings were similar to those reported elsewhere. The time to positivity of cultures varies based on the type of skin sample. This finding needs to be further evaluated in studies with an increased number of cases.

Caracterización epidemiológica, clínica y de laboratorio de esporotricosis en pacientes de un hospital de tercer nivel en Lima-Perú, entre los años 1991 y 2014 / Epidemiological clinical and laboratory characterization of sporotrichosis in patients of a tertiary care hospital in Lima, Peru, from 1991 to 2014

Introducción: La esporotricosis es una afección endémica en numerosos países latinoamericanos y en el resto del mundo. En Perú se concentra en regiones con clima cálido y húmedo, siendo poco conocida en el resto del país. Objetivo: Describir las características epidemiológicas, clínicas y de laboratorio de esporotricosis en pacientes de un hospital de tercer nivel en Lima-Perú, entre los años 1991 y 2014.Método: Estudio descriptivo, retrospectivo, tipo serie de casos. Resultados: Se incluyeron 94 pacientes, la mayoría de los cuales fueron adultos del sexo masculino. Los lugares de adquisición más frecuentes fueron Cajamarca, Apurímac, y Amazonas. Las formas linfo-cutánea y cutánea fija fueron observadas con mayor frecuencia en adultos y, en especial de localización en los miembros superiores. Las localizaciones en la cabeza y el cuello fueron más frecuentes en niños. Co-morbilidades estuvieron presentes en 15% de pacientes, en particular en aquellos con la forma cutánea diseminada. El 78% de los cultivos procedentes de lesiones cutáneas fueron positivos dentro de siete días, y el tiempo de positividad fue mayor en cultivos de biopsia que en las muestras por raspado-aspirado. Conclusiones: Esporotricosis fue adquirida mayoritariamente en zonas del Perú con pobreza extrema. Las características clínicas, epidemiológicas y de laboratorio no difieren de las reportadas en otros estudios. El tiempo de positividad de los cultivos varía según tipo de muestra, lo que deberá ser mejor evaluado en estudios futuros.

Background: Sporothricosis is endemic in numerous Latin American countries and the rest of the world. In Peru is concentrated in regions with warm and humid climate being little known in the rest of the country. Aim: To describe the epidemiological, clinical and laboratory characteristics of patients diagnosed of sporotrichosis in a tertiary-care level hospital in Lima, Peru from 1991 to 2014. Methods: This was a retrospective, case series. Results: Ninety four patients were involved; most of them were male adults. This condition was acquired more frequently in Cajamarca, Apurímac, and Amazonas. Fixed and lymphocutaneous form were the most frequent forms of presentation in adults and were mostly distributed in upper limbs. Lesions located in head and neck were most frequent in children. Comorbidities were present in 15% of patients and were more frequent in those who presented disseminated cutaneous form. Seventy eight percent of cultures from skin lesions were positive within 7 days. The time to positivity of cultures was longer if the sample came from skin biopsies than skin scraping or skin aspiration. Conclusions: Most cases of sporotrichosis were acquired in areas of extreme poverty in Peru. The clinical, epidemiological and laboratory findings were similar to those reported elsewhere. The time to positivity of cultures varies based on the type of skin sample. This finding needs to be further evaluated in studies with an increased number of cases.

Posaconazole treatment of refractory eumycetoma and chromoblastomycosis

Eumicetoma e cromoblastomicose são infecções fúngicas crônicas do tecido subcutâneo que evoluem com aspecto desfigurado, raramente involuindo espontaneamente. A maioria dos pacientes não apresenta melhora sustentada por longo tempo com os tratamentos disponíveis, sendo de grande importância as novas opções terapêuticas. A eficácia do posaconazol, um novo agente antifúngico de amplo espectro do grupo dos triazóis, foi estudada em 12 pacientes com eumicetoma ou cromoblastomicose refratária às terapêuticas antifúngicas disponíveis. Os pacientes receberam por no máximo 34 meses, doses divididas de 800 mg/dia de posaconazol. Resposta clínica parcial ou completa foi considerada como sucesso; doença estável ou falha terapêutica foi considerada como insucesso. Todos os 12 pacientes tinham infecções comprovadas ou prováveis, refratárias à terapêutica padrão preconizada. Sucesso clínico foi registrado em cinco de seis pacientes com eumicetoma e cinco de seis pacientes com cromoblastomicose. Em dois pacientes observou-se doença estável. Como parte do protocolo de extensão do tratamento, dois pacientes com eumicetoma que inicialmente tinham tido sucesso terapêutico e que após um intervalo maior de 10 meses apresentaram recidiva da micose, foram retratados com sucesso com posaconazol. Posaconazol foi bem tolerado durante o longo período de administração (até 1015 dias). A terapêutica com posaconazol foi seguida de sucesso na maioria dos pacientes com eumicetoma ou cromoblastomicose refratária à terapêutica padrão, sugerindo que tal droga possa ser uma importante opção no tratamento de tais doenças.

Recombinant interferon- gamma 1b as adjunctive therapy for AIDS-related acute cryptococcal meningitis.

We conducted a phase 2, double-blind, placebo-controlled study to evaluate the safety and antifungal activity of adjuvant recombinant interferon (rIFN)- gamma 1b in patients with acquired immunodeficiency syndrome and acute cryptococcal meningitis. Patients received 100 or 200 microg of rIFN- gamma 1b or placebo, thrice weekly for 10 weeks, plus standard therapy with intravenous amphotericin B, with or without flucytosine, followed by therapy with fluconazole. End points included conversion of cerebrospinal fluid fungal cultures from positive to negative at 2 weeks, resolution of symptoms, and survival. Among 75 patients, 2-week culture conversion occurred in 13% of placebo recipients, 36% of rIFN- gamma 1b (100 microg) recipients, and 32% of rIFN- gamma 1b (200 microg) recipients. There was a trend toward improved combined mycologic and clinical success in rIFN- gamma 1b recipients (26% vs. 8%; P=.078). Therapy with rIFN- gamma 1b was well tolerated, and there was no apparent influence on serial CD4 cell counts and human immunodeficiency virus load measurements. Adjunctive therapy with rIFN- gamma 1b holds promise for patients with acute cryptococcal meningitis and warrants further study.

Species distribution and antifungal susceptibility profile of Candida spp. bloodstream isolates from Latin American hospitals

From March 1999 to March 2000, we conducted a prospective multicenter study of candidemia involving five tertiary care hospitals from four countries in Latin America. Yeast isolates were identified by classical methods and the antifungal susceptibility profile was determined according to the National Committee for Clinical Laboratory Standards microbroth assay method. During a 12 month-period we were able to collect a total of 103 bloodstream isolates of Candida spp. C. albicans was the most frequently isolated species accounting for 42 percent of all isolates. Non-albicans Candida species strains accounted for 58 percent of all episodes of candidemia and were mostly represented by C. tropicalis (24.2 percent) and C. parapsilosis (21.3 percent). It is noteworthy that we were able to identify two cases of C. lusitaniae from different institutions. In our casuistic, non-albicans Candida species isolates related to candidemic episodes were susceptible to fluconazole. Continuously surveillance programs are needed in order to identify possible changes in the species distribution and antifungal susceptibility patterns of yeasts that may occurs after increasing the use of azoles in Latin American hospitals

Esporotricosis en Abancay, Perú / Sporotrichosis in Abancay, Perú

En la ciudad de Abancay se realizó un estudio con la finalidad de conocer algunas de las características de la esporotricosis. Se efectuó una encuesta clínico-epidemiológica, con toma de muestras de lesiones para determinar la presencia de Sporothrix schenckii mediante cultivo, en 39 pacientes sospechosos de esporotricosis que acudieron a consulta externa del Centro Médico Santa Teresa, entre enero y octubre de 1986. Los criterios de inclusión fueron: características de lesiones, duración de la enfermedad y falta de respuesta a otros tratamientos. Se encontró que en esta ciudad la esporotricosis se presenta más frecuentemente en los menores de 15 años; la mayor parte presenta una lesión única y generalmente en la cara; la variedad de lesión más frecuente fue la cutánea fija. Se concluye que Abancay es una zona endémica de esporotricosis; sin embargo falta estudiar más esta micosis para establecer su mecanismo de transmisión y el nicho ecológico, y así poder determinar las medidas de control más adecuadas.