How I approach: the transplant recipient with fever and pulmonary infiltrates.

Recipients of hematopoietic stem cell transplants and solid organ transplants frequently develop pulmonary infiltrates from both infectious and non-infectious etiologies. Differentiation and further characterization of microbiologic etiologies-viral, bacterial, and fungal-can be exceedingly challenging. Pediatric patients face unique challenges as confirmatory evaluations with bronchoscopy or lung biopsy may be limited. A generalizable approach to diagnosing and managing these conditions has not been well established. This paper aims to summarize our initial clinical approach while discussing the relative evidence informing our practices. A pediatric patient with characteristic infiltrates who has undergone HSCT is presented to facilitate the discussion. Generalizable approaches to similar patients are highlighted as appropriate while highlighting considerations based on clinical course and key risk factors.

Clinical and histopathological correlation of oral malignancy and potentially malignant disorders based on a screening program at high-risk population in Tamil Nadu, India.

Background: There is a high incidence of oral cancer and oral potential malignant disorder observed in southeast Asian countries such as India. Our study aimed to assess the correlation between screening and histopathological diagnosis and to predict the specificity and sensitivity of chair-side/field-based assessment of the oral lesion. Materials and methods: A total of 40,852 subjects aged between 20 and 60 years were screened in the 1st phase of the study, suspected lesions were stained with toluidine blue (Manufactured by Otto Chemicals private limited, India) at two time points, those who stained positively during the two points were taken up for biopsy. Provisional diagnosis was later correlated with histopathological diagnosis. Results: Subjects who underwent biopsy had a mean age of (49.01 ± 9.8 years), Leukoplakia (1.5%) was the most common lesion observed among tobacco users, interestingly it had the least correlation (39.6%) in diagnosis, Overall sensitivity (88%) and a positive predictive value (80%) was high for clinical diagnosis of OPMD in our study. Conclusion: Correlation of clinical and histopathological diagnosis observed in our study confirms higher yield of true positives while screening in remote and vulnerable populations, which would assure a better quality of life for these subjects.

Pediatric Invasive Fungal Risk Score in Cancer and Hematopoietic Stem Cell Transplantation Patients With Febrile Neutropenia.

BACKGROUND: Invasive fungal diseases (IFDs) are opportunistic infections that result in significant morbidity and mortality in pediatric oncology patients. Predictive risk tools for IFD in pediatric cancer are not available. METHODS: We conducted a 7-year retrospective study of pediatric oncology patients with a diagnosis of febrile neutropenia at UCM Comer Children's Hospitals. Fourteen clinical, laboratory, and treatment-related risk factors for IFD were analyzed. Stepwise variable selection for multiple logistic regression was used to develop a risk prediction model for IFD. Two comparative analyses have been conducted: (i) all suspected IFD cases and (ii) all proven and probable IFD cases. RESULTS: A total of 667 febrile neutropenia episodes were identified in 265 patients. IFD was diagnosed in 62 episodes: 13 proven, 27 probable, and 22 possible. In the final multiple logistic regression models, 5 variables were independently significant for both analyses: fever days, neutropenia days, hypotension, and absolute lymphocyte count <250 at the time of diagnosis. The odds ratio and a relative weight for each factor were then calculated and summed to calculate a predictive score. A risk score of ≤4 and ≤5 (10/11 maximum) for each model signifies low risk, respectively (<1.2% incidence). Model discrimination was evaluated by the area under the receiver operator characteristics curve with an area under the curve of 0.95/0.94 for each model. CONCLUSION: Our prediction IFD risk models perform well, are easy-to-use, and are based on readily available clinical data. Profound lymphopenia absolute lymphocyte count <250 mm3 could serve as a new important prognostic marker for the development of IFD in pediatric cancer and hematopoietic stem cell transplant patients.

Clinical Utility of Anaerobic and Fungal Blood Cultures in the Pediatric Oncologic Population.

BACKGROUND: If there is a concern for sepsis in a pediatric patient an aerobic blood culture is obtained. A febrile or ill oncology patient will often be evaluated with aerobic, anaerobic, and fungal blood cultures. There is to our knowledge little evidence to confirm the added benefit of broadly obtaining these cultures. METHODS: A retrospective analysis of blood cultures from patients in the oncology and hematopoietic stem cell transplant wards at Children's National Medical Center between January 2010 and April 2017. Positive anaerobic and fungal cultures were evaluated for corollary positive aerobic cultures from the same time frame (+/-24 h). Unique isolates were designated as those positive anaerobic and fungal cultures without positive aerobic cultures and evaluated with detailed chart review. RESULTS: A total of 10,950 cultures were evaluated during the study period: 6579 aerobic, 2391 anaerobic cultures, 1980 fungal. In total, 419 positive aerobic, 140 positive anaerobic, and 43 positive fungal cultures were reviewed. Among these, 22 unique anaerobic cultures and 21 unique fungal cultures met case criteria. Only 7 cultures of obligate anaerobes were observed: 4 Clostridial spp., 2 Propionobacterium acnes, and 1 Peptostreptococcus spp. Thirteen of 21 fungal isolates consisted of a single colony and were regarded as probable contaminants. Penicillium, Cladosporium, and dematiaceous molds were in greatest frequency. Potential risk factors for patients with breakthrough isolates were evaluated and described. CONCLUSIONS: There is little increased yield from the use fungal and anaerobic blood cultures in addition to aerobic blood cultures in the routine evaluation of pediatric oncology and bone marrow transplant patients. Fungal and anaerobic blood cultures and should be reserved for cases with high clinical suspicion.

Central Line-Associated Mucor velutinosus Bloodstream Infection in an Immunocompetent Pediatric Patient.

We report here the isolation of Mucor velutinosus from multiple blood cultures performed on samples from Broviac catheters and culture of a Broviac insertion-site wound sample from a 6-year-old boy with a history of intestinal failure secondary to chronic intestinal pseudo-obstruction, parenteral nutrition, and jejunostomy tube dependence. Examination of a slide from the culture revealed the presence of wide nonseptate hyphae with sporangiophores, columella, and chlamydospores. The fungal isolate was sent to the National Institutes of Health for further evaluation and was identified as Mucor velutinosus by matrix-assisted laser desorption ionization-time-of-flight mass spectrometry and genomic sequencing. The patient was treated successfully with intravenous amphotericin B and prompt removal of his central line. To the best of our knowledge, this is the first case of M velutinosus bloodstream infection in a child without cancer.

Immobilized lipase from Schizophyllum commune ISTL04 for the production of fatty acids methyl esters from cyanobacterial oil.

Novel lipase from model mushroom Schizophyllum commune strain ISTL04 produced by solid state fermentation of Leucaena leucocephala seeds, was immobilized onto Celite for enzymatic FAMEs production from cyanobacterial endolith Leptolyngbya ISTCY101. The isolate showed vigorous growth and produced remarkable lipase activity of 146.5 U g(-1) dry solid substrate, without any external lipase inducer. Single-factor experiments were carried out to study the effects of various reaction parameters on the FAMEs yield. The best conditions for enzymatic transesterification as revealed by the results were: 1:3 oil to methanol molar ratio, added at 3h intervals, 12% water content, 1581.5 U g(-1) immobilized lipase, temperature 45 °C, and time 24h. Under these conditions, the maximum FAMEs yield reached 94%. The immobilized lipase was able to produce >90% of the relative FAMEs yield after four repeated transesterification cycles. This immobilized lipase exhibited potential for application in biodiesel industry.