Diagnosis and treatment monitoring of toenail onychomycosis by reflectance confocal microscopy: prospective cohort study in 58 patients.

BACKGROUND: The clinical presentation of onychomycosis is often nonspecific and can lead to inappropriate antifungal therapy. Available mycologic tests share many drawbacks. OBJECTIVE: We sought to evaluate the accuracy of reflectance confocal microscopy (RCM) for the diagnosis of onychomycosis compared with standard mycologic tests. METHODS: In all, 58 patients with suspected onychomycosis were enrolled prospectively. RCM, potassium hydroxide preparation, and fungal culture were performed at baseline and after treatment in patients with confirmed onychomycosis. RCM diagnosis of onychomycosis was based on the presence of filamentous and/or roundish structures in the nail plate, corresponding respectively to septate hyphae and/or arthroconidia. RESULTS: Of patients, 46 of 58 were correctly classified by RCM, with a diagnosis yield of 79.3%, sensitivity of 52.9%, specificity of 90.2%, positive predictive value of 69.2%, and negative predictive value of 82.2%. The use of a handheld RCM imager permitted a faster examination with the same accuracy. RCM performed after treatment in 9 patients showed a normal nail plate, and healing was confirmed by mycologic tests or by follow-up. LIMITATIONS: Existing RCM scanner heads are not intended for nail examination. CONCLUSION: RCM has excellent specificity and can be used as a rapid, office-based test to strengthen the prescription of antifungal therapy and for follow-up. Technical improvement could aid sensitivity.

MALDI-TOF mass spectrometry identification of filamentous fungi in the clinical laboratory.

This study aimed to validate the effectiveness of a standardised procedure for the MALDI-TOF mass spectrometry (MS)-based identification on a large sample of filamentous fungi routinely identified in university hospitals' laboratories. Non-dermatophyte filamentous fungi prospectively isolated in the routine activity of five teaching hospitals in France were first identified by conventional methods in each laboratory and then by MS in one centre. DNA sequence-based identification resolved discrepancies between both methods. In this study, of the 625 analysed filamentous fungi of 58 species, 501 (80%) and 556 (89%) were correctly identified by conventional methods and MS respectively. Compared with the conventional method, MS dramatically enhanced the performance of the identification of the non-Aspergillus filamentous fungi with a 31-61% increase in correct identification rate. In conclusion, this study on a large sample of clinical filamentous fungi taxa demonstrates that species identification is significantly improved by MS compared with the conventional method. The main limitation is that MS identification is possible only if the species is included in the reference spectra library. Nevertheless, for the routine clinical laboratory, MS provides the means to attain markedly accurate results in filamentous fungi identification, which was previously restricted to only a few reference laboratories.

Fatal peritonitis caused by Rhizopus microsporus.

A 52-year-old woman with a history of Crohn's disease was admitted due to peritonitis which followed an intestinal perforation. After transitory treatment with voriconazole, resolution of the infection was complicated by recurring peritonitis resulting from necrosis and perforation of the left colon which ultimately lead to the death of the patient. Microscopic examination of the peritoneal fluid revealed the presence of broad, irregular hyphae and culture of the fluid yielded Rhizopus microsporus. The identification of the fungus was confirmed by its characteristic microscopic morphology and sequencing of the ITS region of the rDNA. The histopathologic examination of the colon tissue demonstrated the presence of broad, non-septate hyphae and the same fungus was again isolated in culture.

Adjuvant corticosteroid therapy in 2 children with hepatosplenic candidiasis-related IRIS.

First described in HIV-infected patients who recently initiated highly active antiretroviral therapy, the immune reconstitution inflammatory syndrome (IRIS) is best characterized as a collection of inflammatory disorders triggered by rapid resolution of immunosuppression. Treatment of IRIS is a clinical challenge due to the variety of clinical presentations and the presence of multiple pathogens capable of causing the syndrome. Hepatosplenic candidiasis, an uncommon form of invasive Candida species infection, was recently suggested to belong to the spectrum of fungus-related IRIS. We report 2 cases of probable hepatosplenic candidiasis according to the guidelines of the European Organization for Research and Treatment of Cancer and the Mycosis Study Group, occurring in pediatric patients with acute leukemia during rapid neutrophil recovery after cytotoxic chemotherapy. In both cases, abdominal computed tomography scan revealed multiple hepatic micronodules, and liver biopsy showed nonspecific granulomatous lesions. Hepatosplenic candidiasis symptoms (fever, nausea and vomiting, abdominal pain) resolved within 2 days after adjunction of corticosteroid therapy to antifungal treatment. Inflammatory markers and related radiologic abnormalities decreased or disappeared within 1 month. Recovery of neutrophil count in a context of hepatosplenic candidiasis may result in a heightened inflammatory response. Corticosteroid therapy in this setting is associated with prompt resolution of the symptoms.

[Pneumonia caused by Cunninghamella bertholletiae in a patient with acute lymphoblastic leukemia]. / Pneumopathie à Cunninghamella bertholletiae compliquant une leucémie aigüe lymphoblastique.

Pulmonary mucormycosis occur in immunosuppressed patients with a neutropenic treatment or a malignant neoplasia. Although the histological study alone cannot enable species identification, the pathologist usually makes the diagnosis of mucormycosis and can eliminate other filamentous mycoses such as aspergillosis or scedosporiosis. Pulmonary infection caused by Cunninghamella bertholletiae is a very rare lung mucormycosis, particularly in young patients. The histological features of this filamentous mycosis are unusual making the diagnosis of mucormycosis difficult. Mycological study is then crucial for the diagnosis. We report a case of a pulmonary infection caused by Cunninghamella bertholletiae occurring in a young girl with acute lymphoblastic leukemia.

Putative Diphyllobothrium nihonkaiense acquired from a Pacific salmon (Oncorhynchus keta) eaten in France; genomic identification and case report.

We report here a likely case of Diphyllobothrium nihonkaiense contracted in France through the consumption of a Pacific salmon imported from Canada. The species diagnosis was made by molecular analysis of two mitochondrial genes (COI & ND3). This case is rather unusual in that D. nihonkaiense has never been reported along the Pacific coast of North America.

Usefulness of frozen section in rhinocerebral mucormycosis diagnosis and management.

AIMS: Rhinocerebral mucormycosis (RCM) is a well-described fulminant fungal infection that presents acutely in patients with ketoacidosis and immunosuppression. Very early diagnosis, established with the demonstration of characterised hyphae in tissues, greatly improves the prognosis of RCM. In this regard, the specificity and the sensitivity of frozen section for the diagnosis and the surgical debridement of RCM were evaluated in this study. METHODS AND RESULTS: Frozen section was performed for the diagnosis (six of seven cases) and surgical treatment (three of seven cases) of RCM. In all cases, diagnosis was made by frozen section and confirmed by histological examination. Frozen section allowed radical surgical excision of infected tissue. In all cases, invasive, broad-based non-septated hyphae with branching at right angles were well demonstrated on toluidine blue staining. Cultures were positive for Rhizopus oryzae in three of seven cases. Outcome was favourable for five of seven patients and two patients died after the diagnosis. CONCLUSIONS: Frozen section is a specific and sensitive method to make both a quick initial diagnosis of RCM and to successfully eradicate the tissue infected by organisms belonging to the order Mucorales.

Chronic pulmonary penicilliosis due to Penicillium marneffei: late presentation in a french traveler.

We report a case of pulmonary penicilliosis due to Penicillium marneffei in an immunocompetent French patient with chronic obstructive pulmonary disease, who had traveled in endemic countries several years before. The long interval between exposure and initial symptoms of infection, and relapse despite prolonged voriconazole treatment are unusual features.

Usefulness of molecular biology performed with formaldehyde-fixed paraffin embedded tissue for the diagnosis of combined pulmonary invasive mucormycosis and aspergillosis in an immunocompromised patient.

Immunocompromised patients who develop invasive filamentous mycotic infections can be efficiently treated if rapid identification of the causative fungus is obtained. We report a case of fatal necrotic pneumonia caused by combined pulmonary invasive mucormycosis and aspergillosis in a 66 year-old renal transplant recipient. Aspergillus was first identified during the course of the disease by cytological examination and culture (A. fumigatus) of bronchoalveolar fluid. Hyphae of Mucorales (Rhizopus microsporus) were subsequently identified by culture of a tissue specimen taken from the left inferior pulmonary lobe, which was surgically resected two days before the patient died. Histological analysis of the lung parenchyma showed the association of two different filamentous mycoses for which the morphological features were evocative of aspergillosis and mucormycosis. However, the definitive identification of the associative infection was made by polymerase chain reaction (PCR) performed on deparaffinized tissue sections using specific primers for aspergillosis and mucormycosis. This case demonstrates that discrepancies between histological, cytological and mycological analyses can occur in cases of combined mycotic infection. In this regard, it shows that PCR on selected paraffin blocks is a very powerful method for making or confirming the association of different filamentous mycoses and that this method should be made available to pathology laboratories.

[Prevention of fungal infections related to the water supply in French hospitals: proposal for standardization of methods]. / Surveillance mycologique de l'eau pour la prévention des mycoses invasives dans les établissements de santé: propositions de standardisation des méthodologies.

OBJECTIVES: The aims of this study were to assess the risk of fungal infections related to the water supply in several hospitals and to clarify the appropriate methodology in order to standardize the technical conditions of the controls and develop guidelines. It was conducted in 10 university hospital centers across the country from February 2004 through March 2005. METHOD: A preliminary study allowed us to optimize the mycological analysis. The study was conducted under the same conditions as for bacteriological controls: water filtration through a cellulose acetate membrane cultured on agar. Departments with the highest patient risk were selected, including hematology, organ transplantation, and burn units. We selected 98 sites and sampled both water and water-related surfaces at each: three one-liter water samples (the first flow, cold and hot water) and two or three surface samples (inside the tap, pommel of the shower and siphon). At each site, a form was filled to specify its location in the unit, any water treatment (chlorine or other), filtering, and temperature. Water from taps equipped with sterilized filtration was sampled without the filter. RESULTS: There was a significant difference (p=0.039) in the number of positive cultures between the three types of water sampled: hot water (>50 degrees C) was colonized less often than first flow or cold water. Only 4% of the hot-water samples had positive cultures, compared to the 52% of the cold-water samples. Except in two hospitals with generalized contamination of the water pipes (one with Exophiala spp and the other with Fusarium spp), colonization was usually slight. Cold water was more colonized than hot water, but 79% of the samples yielded fewer than 5CFU/L. Dematiaceous hyphomycetes were isolated; Aspergillus spp were rare. The number of CFU in surface samples (that is, biofilms) was higher (mean=15 CFU per sample) but surfaces were positive less often than water (13% compared with 43% of all water samples). Sampling from siphons was productive more often than from taps (23%), but the molds isolated differed from those in the related water. Relations to bacterial flora and P. aeruginosa were also studied, together with the effects of chemical treatment. CONCLUSION: Current regulations require only bacteriological survey. The absence of knowledge about the threshold of contamination at which there is a risk of nosocomial invasive fungal infections makes it difficult to impose routine monitoring. Mycological surveys of water are required during hospital renovation, plumbing work, pipe maintenance and when air samples are negative during nosocomial infection investigations.

Invasive fungal dermatitis in a 770 gram neonate.

A 770 g birthweight, 25-weeks gestation infant girl was born from a bigeminal pregnancy. Six days later she developed erythematous "diaper dermatitis" and maceration of the flexural areas. Despite topical antifungal therapy, erythematous plaques appeared 2 days later on the back. Within less than 24 hours, skin erosions with crusting appeared and spread over the whole body. Candida albicans was found in cutaneous scales, and blood, umbilical catheter, and cerebrospinal fluid cultures. In spite of intravenous fluconazole therapy, her general condition deteriorated and she died 2 days later. This premature neonate had a typical case of invasive fungal dermatitis, which is characterized by diffuse erosive and crusting cutaneous lesions appearing several days after birth and a high rate of systemic fungal infection (mainly but not exclusively) due to Candida sp. Mortality is high and prompt diagnosis and initiation of antifungal therapy appears to be the most important factor for survival.

Fluconazole therapy for Candida albicans urinary tract infections in infants.

Candiduria is rare in newborns and infants, occurring most often in patients with risk factors. When associated with a candidal bezoar in the urinary tract, candiduria is usually treated by systemic amphotericin B and flucytosine plus local irrigation with amphotericin B. We describe the successful treatment of five newborns with a urinary tract infection, on major urological malformations, due to Candida albicans (including three with a candidal bezoar) by fluconazole alone. No adverse effects or recurrences were observed. Fluconazole therapy permits early discharge from the hospital and seems suitable for infants and newborns with a C. albicans urinary tract infection.