A rare case of Saprochaete capitata fungemia in a critical ill patient without hematologic and oncological disorders / Fungemia por Saprochaete capitata en un paciente grave sin alteraciones hematológicas y oncológicas

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First Case of Fungemia Due to Pseudozyma aphidis in a Pediatric Patient with Osteosarcoma in Latin America.

We report the first case of blood infection due to Pseudozyma aphidis in Latin America. We contribute evidence showing this organism to be a potential human pathogen, and we provide new data about its identification, drug susceptibility, and treatment outcome.

Clinical Characteristics, Laboratory Identification, and In Vitro Antifungal Susceptibility of Yarrowia (Candida) lipolytica Isolates Causing Fungemia: a Multicenter, Prospective Surveillance Study.

Our case series showed that uncomplicated Yarrowia lipolytica fungemia might be treated with catheter removal alone. The Vitek 2 YST identification (ID) card system, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), and internal transcribed spacer and 25S nuclear ribosomal DNA (nrDNA) gene sequencing provided reliable identification. All isolates had low MICs to voriconazole, echinocandins, and amphotericin B.

[Molecular markers: an important tool in the diagnosis, treatment and epidemiology of invasive aspergillosis]. / Marcadores moleculares: una herramienta importante en el diagnóstico, tratamiento y epidemiología de la aspergilosis invasora.

Increase in the incidence of invasive aspergillosis has represented a difficult problem for management of patients with this infection due to its high rate of mortality, limited knowledge concerning its diagnosis, and therapeutic practice. The difficulty in management of patients with aspergillosis initiates with detection of the fungus in the specimens of immunosuppressed patients infected with Aspergillus fumigatus; in addition, difficulty exists in terms of the development of resistance to antifungals as a consequence of their indiscriminate use in prophylactic and therapeutic practice and to ignorance concerning the epidemiological data of aspergillosis. With the aim of resolving these problems, molecular markers is employed at present with specific and accurate results. However, in Mexico, the use of molecular markers has not yet been implemented in the routine of intrahospital laboratories; despite the fact that these molecular markers has been widely referred in the literature, it is necessary for it to validated and standardized to ensure that the results obtained in any laboratory would be reliable and comparable. In the present review, we present an update on the usefulness of molecular markers in accurate identification of A. fumigatus, detection of resistance to antifugal triazoles, and epidemiological studies for establishing the necessary measures for prevention and control of aspergillosis.

El incremento en la incidencia de la aspergilosis invasora representa un grave problema para el tratamiento de pacientes con esta micosis, debido a su elevada tasa de mortalidad por deficiencias diagnósticas y terapéuticas. Éstas se han atribuido a la dificultad para detectar Aspergillus fumigatus, principal agente etiológico de esta micosis, en las muestras biológicas de pacientes inmunosuprimidos, que son los principales afectados por el hongo; además por la resistencia a los antifúngicos como consecuencia del uso incontrolado de éstos, a nivel profiláctico y terapéutico, y el desconocimiento de aspectos epidemiológicos de la aspergilosis. En la actualidad, para superar estas limitaciones se han empleado marcadores moleculares. En México su uso aún no está implementado en la rutina de los laboratorios intrahospitalarios, porque a pesar de que se han reportado ampliamente en la bibliografía, hace falta validarlos y estandarizarlos para asegurar que los resultados que se obtengan en cualquier laboratorio sean confiables y comparables. En este trabajo se presenta una revisión actualizada de la utilidad de los marcadores moleculares en la identificación certera de A. fumigatus en la detección de resistencia a los antifúngicos triazólicos y en estudios epidemiológicos para establecer las medidas necesarias en la prevención y control de la aspergilosis.

Sporopachydermia cereana fungaemia in refractory leukaemia presenting as breakthrough infection during micafungin therapy.

The Sporopachydermia cereana species lives in decaying stems of cactus and is exceptionally rare as a human pathogen. A 57-year-old man with therapy-refractory acute promyelocytic leukaemia developed severe neutropaenia. After about 3 weeks of micafungin used as prophylaxis, he developed high fever, multiple pulmonary nodular infiltrates and a painful leg lesion. Blood culture yielded a yeast which was not identified by the Vitek 2 system. On ITS1-5.8S-ITS2 gene sequencing, the isolate was identified as S. cereana. Antifungal sensitivity by the Etest showed that the minimum inhibitory concentration for fluconazole was 0.75 µg/mL, and for anidulafungin, it was >32 µg/mL. He responded to liposomal amphotericin B but later died of Escherichia coli septicaemia. There were no cactus plants in the vicinity, suggesting that S. cereana might have alternative habitats.

Rhodotorula fungemia: two cases and a brief review.

Rhodotorula is emerging as an important cause of nosocomial and opportunistic infections. We present two cases of Rhodotorula mucilaginosa fungemia diagnosed over a period of 3 months at our hospital. The first case was of a pre-term neonate in the neonatal ICU who presented with respiratory failure and sepsis. The second involved an adult female who had been injured in a road traffic accident requiring an operation for a hematoma and was later shifted to the medical ICU. For a new hospital like ours, finding two cases of Rhodotorula fungemia within a span of 3 months prompted us to describe them in this report. These cases emphasize the emerging importance of Rhodotorula mucilaginosa as a pathogen and the importance of identification and MIC testing for all fungal isolates recovered from the blood stream.

Invasive candidiasis in the intensive care unit.

Invasive fungal disease by Candida spp. is on the rise in the modem era of prolonged patient survival by virtue of improved critical care measures, novel chemotherapy regimens, and increasing immunosuppression following organ transplants. Invasive candidiasis (IC) in the setting of an intensive care unit results in prolonged hospital stay and increased morbidity. Clinical suspicion plays a major role in the diagnosis of IC, as current laboratory methods are not very sensitive. Various serum markers and molecular techniques are under development to improve diagnostic strategies. Treatment options involve an expanding spectrum of antifungals. Knowledge of local epidemiology and the risk factors that predispose patients to this disease are essential for effective patient care in an intensive care setting.

The emerging life-threatening opportunistic fungal pathogen Kodamaea ohmeri: optimal treatment and literature review.

BACKGROUND/PURPOSE: The yeast Kodamaea ohmeri rarely causes life-threatening human infections. However, risk factors, laboratory diagnoses, and treatments for K. ohmeri infection have been limited, and the optimal therapy for K. ohmeri infection has not been identified. METHODS: Twenty cases of K. ohmeri infection have been reported in the English medical literature. We present two new cases of K. ohmeri fungemia. We investigated the nature and treatment of K. ohmeri infections using minimum inhibitory concentrations of antifungal agents and by comparing the two cases with those described in the literature. RESULTS: From March 1998 to December 2008, a total of 22 patients with K. ohmeri infections were studied. Hematological malignancies and diabetes were the most common co-morbidities for K. ohmeri infections, with crude prevalence rates of 27.3% and 18.2%, respectively. The K. ohmeri isolates showed less susceptibility to fluconazole but greater susceptibility to amphotericin B [15/25 isolates (60%) vs. 25/25 isolates (100%), respectively]. Good outcomes (8/9 cases; 88.9%) were found following removal of indwelling catheters and implants. In addition, voriconazole and echinocandins, such as caspofungin and micafungin, also showed excellent minimum inhibitory concentrations against K. ohmeri. CONCLUSION: K. ohmeri should not be regarded as a contaminant of blood cultures. Favorable outcomes for this potentially life-threatening infection are promoted by the removal of indwelling catheters; furthermore, outcomes are associated with optimal antifungal regimens, especially voriconazole and echinocandins.

Audit of laboratory mycology services for the management of patients with fungal infections in the northwest of England.

BACKGROUND: Fungal infection is increasingly recognised as an important cause of morbidity and mortality, especially in immunocompromised patients. Little information exists on laboratory services available and the methods used by general microbiology laboratories to diagnose these important infections. AIM: To investigate the services microbiology laboratories in northwest England provide towards the diagnosis and management of superficial and deep fungal infections. METHODS: A questionnaire was sent to laboratories to get a holistic view of the support given to clinicians looking after patients with fungal infections. The aim was not to investigate details of each laboratory's standard operating procedures. The completed questionnaires, which formed the basis of this report, were returned by all 21 laboratories which were recruited. This study was conducted between March 2004 and September 2004. RESULTS: Services were provided to District General Hospitals and to six tertiary centres, including eight teaching hospitals by 16 laboratories. Their bed capacity was 250-1300 beds. Total specimens (including bacterial and viral) processed annually were 42 000-500,000 whereas fungal ones were 560-5400. CONCLUSION: In most microbiology laboratories of northwest England, clinicians were aware of the potential of fungal pathogens to cause infections especially in immunocompromised patients. Additional measures such as prolonged incubation of samples were introduced to improve fungal yield from patients at high risk. It is necessary to train and educate laboratory and medical staff about the role of serology and molecular methods in diagnosis and management of patients with fungal infection.

Trichosporon asahii fungemia in a patient with non-hematological malignancy.

Trichosporon fungemia is usually seen in neutropenic patients with underlying hematological malignancies. In this report we describe a fatal case of Trichosporon asahii fungemia in a non-neutropenic patient with a non-hematological malignancy. For 1 week the patient exhibited hematuria, weakness, easy fatigability and headaches. At admission she had anemia, renal failure and evidence of right hydronephrosis and bladder wall masses as detected by CT scan. She did not have a history of tobacco abuse, contact with urinary carcinogens or Schistosoma infestation; her clinical picture was suggestive of bladder cancer. After some investigations the patient underwent radical cystectomy and ileal conduit surgery because of transitional cell carcinoma in the urinary bladder. After an initial uneventful improvement postoperatively the patient deteriorated and died of septic shock despite all reanimation efforts and antibiotherapy including fluconazole. The blood culture obtained 4 days before the patient died revealed T. asahii, which was isolated on the day she died and found to be resistant to fluconazole and caspofungin. This report suggests that clinicians remain aware that T. asahii fungemia may develop in clinically deteriorated patients even if they do not have a hematological malignancy.

Utility of real-time antifungal susceptibility testing for fluconazole in the treatment of candidemia.

Our study prospectively examined the use of real-time antifungal susceptibility testing among 119 patients with candidemia at a large tertiary university medical center over a 1-year period. Susceptibility results to fluconazole were reported to physicians a mean of 5.1 days after the initial positive blood culture for Candida. Physicians believed that receiving antifungal susceptibility testing results was helpful and not infrequently altered therapy on the basis of results. Outcomes, including mortality and resolution of infection, among 20 (17%) patients with fluconazole-resistant and fluconazole-susceptible dose-dependent isolates were relatively poor compared to those among patients with fluconazole-susceptible isolates, but probably reflect severity of illness. Routine susceptibility testing as an adjunct to the treatment of candidemia has significant potential and warrants further study.

Successful treatment of pulmonary invasive aspergillosis with voriconazole in patients who failed conventional therapy.

BACKGROUND: The incidence of fungal infections, including those due to Aspergillosis species has continued to increase in recent years. Invasive aspergillosis remains an important cause of morbidity and mortality, despite therapeutics interventions. PATIENTS AND METHODS: We reported five cases of invasive pulmonary aspergillosis treated with voriconazole failing to respond to conventional treatments. RESULTS: The clinical and radiological resolution of pulmonary aspergillosis reported in these cases following therapy with voriconazole is remarkable, considering the infections had proved refractory to standard antifungal therapies. Long-term therapy (in two cases > or = 1 year, in one case 6 months) was very well tolerated by patients who were unable to tolerate other antifungal agents. CONCLUSION: Therapy with voriconazole offers a new therapeutic option for otherwise difficult-to-treat infections and the potential to significantly improve the management of Aspergillosis infections.

Colony morphology switching of Candida lusitaniae and acquisition of multidrug resistance during treatment of a renal infection in a newborn: case report and review of the literature.

Candida lusitaniae is an emerging opportunistic pathogen which exhibits an unusual antifungal susceptibility pattern. We describe a case of fatal renal infection due to C. lusitaniae in a very low birth weight neonate who was treated with short courses of fluconazole given alternately with amphotericin B. A colony morphology switching was detected on the standard primary culture medium by changes in colony size. Switching was shown to affect deeply the susceptibility to amphotericin B. Afterwards, the switched phenotype developed a cross resistance to fluconazole and itraconazole. Several issues raised by this case are discussed in the light of an extensive review of the literature. Our observations point out the importance of both the detection of colony morphology switching and the close monitoring of antifungal susceptibility in the management of infections due to C. lusitaniae. A judicious therapeutic strategy should prevent the acquisition of multidrug resistance during antifungal therapy.

Outbreak of Candida rugosa candidemia: an emerging pathogen that may be refractory to amphotericin B therapy.

Candida rugosa has been rarely reported as a human pathogen. We retrospectively evaluated a cluster of Candida rugosa candidemia cases occurring in six hospitalized patients from a tertiary care teaching hospital in São Paulo, Brazil. Genetic relatedness among the six C. rugosa outbreak isolates was characterized by RAPD assay using 3 different 10-mer primers and by pulsed field gel electrophoresis. The source of the outbreak was not identified. All patients had been subjected to invasive medical procedures, including central venous catheterization, surgery or dialysis. Two patients were undergoing amphotericin B therapy prior to the onset of candidemia. The crude mortality rate was very high, despite antifungal therapy. C. rugosa may represent an emerging pathogen associated with invasive medical procedures, able to infect immunocompetent hosts causing serious systemic infection refractory to amphotericin B therapy.

Hematogenous infections due to Candida parapsilosis: changing trends in fungemic patients at a comprehensive cancer center during the last four decades.

This study was performed to evaluate trends in species distribution in patients' with hematogenous candidiasis at a comprehensive cancer center. The results of a retrospective analysis from January 1, 1993 to December 31, 1998 were compared with prior reports from Memorial Sloan-Kettering Cancer Center in the last forty years. In 570 total episodes since 1974, 43.9% were due to Candida albicans. During 1990's, C. parapsilosis emerged as the most frequent yeast species in the non-C. albicans group (36.1% during 1993-1998 from 20.9% 1974-1982; p < 0.01). An increase in C. krusei from 5.9% (1974-1982) to 10.5% during the recent six years (1993-1998) was also noticed. The proportion of C. tropicalis among non-albicans fungemia during 1974-1982 was 42.8%, whereas in 1993 to 1998 a marked decline in C. tropicalis hematogenous infection was observed (27.8%; p < 0.01). During 1998, the incidence of candidemia declined from 7.1% (1972-1973) and 6.5% (1982) to 3.4% (p < 0.01), and improved survival among fungemic patients (33% mortality in 1998; 77.3% during 1974-1982; p < 0.001) was encouraging. The increase in C. parapsilosis bloodstream invasion during 1990's was associated with a significant reduction in the endogenous non-albicans Candida tropicalis infection that probably resulted in part due to the common prophylaxis, and/or preemptive fluconazole given routinely in high-risk patients undergoing treatment for cancer. The widespread use of extraneous implantable and/or semi-implantable indwelling intra-vascular devices may also have played an important role in promoting (exogenous) C. parapsilosis infection. This study emphasizes the importance of periodic evaluation of candidemia, especially at centers caring for patients at risk.

Improved detection of Malassezia species in lipid-supplemented Peds Plus blood culture bottles.

The growth of Malassezia species in BACTEC Peds Plus blood culture bottles was optimized by using various lipid supplements. Palmitic acid (3%, wt/vol) was superior and overcame the inhibitory effect of blood in mock clinical specimens. Palmitic acid (3%) supplementation of Peds Plus bottles may improve recovery of Malassezia species in the BACTEC NR 660.