Cladophialophora bantiana brain abscess with lymphadenitis.

Cerebral phaeohyphomycosis refers to central nervous system infection by dematiaceous mould or by dark walled fungi which contain the dark pigment melanin in their cell wall which adds to the virulence of fungus. These dematiaceous fungi can cause a variety of central nervous infections including invasive sinusitis, brain abscess, meningitis, myelitis and arachnoiditis. Cladophialophora bantiana among these dematiaceous fungi is the most common cause of brain abscess in immunocompetent and immunocompromised individuals and is known to occur worldwide though is predominantly reported from subtropical regions especially the Asian subcontinent. It is difficult to differentiate these abscesses radiologically from high-grade gliomas, primary central nervous system lymphoma or other infections including toxoplasmosis, nocardiosis, tuberculosis and listeriosis. We describe a 19-year-old male patient with a cerebral abscess caused by C. bantiana where the diagnosis could be suspected by typical MR spectroscopic findings and by identifying the fungus from a lymph node biopsy.

Fungal necrotizing fasciitis, an emerging infectious disease caused by Apophysomyces (Mucorales) / Fascitis necrotizante fúngica, una enfermedad infecciosa emergente causada por Aphophysomyces (Mucorales)

Background: The mucoralean fungi are emerging causative agents of primary cutaneous infections presenting in the form of necrotizing fasciitis. Aims: The aim of this study was to investigate a series of suspected necrotizing fasciitis cases by Apophysomycesspecies over one-year period in a northern Indian hospital. Methods: The clinical details of those patients suspected to suffer from fungal necrotizing fasciitis were recorded. Skin biopsies from local wounds were microscopically examined and fungal culturing was carried out on standard media. The histopathology was evaluated using conventional methods and special stains.Apophysomyces isolates were identified by their morphology and by molecular sequencing of the internal transcribed spacer (ITS) region of the ribosomal genes. Antifungal susceptibility testing was carried out following EUCAST guidelines and treatment progress was monitored. Results: Seven patients were found to be suffering from necrotizing fasciitis caused by Apophysomyces spp. Six isolates were identified as Apophysomyces variabilis and one as Apophysomyces elegans. Five patients had previously received intramuscular injections in the affected area. Three patients recovered, two died and the other two left treatment against medical advice and are presumed to have died due to their terminal illnesses. Posaconazole and terbinafine were found to be the most active compounds against A. variabilis, while the isolate of A. elegans was resistant to all antifungals tested. Conclusions: Apophysomyces is confirmed as an aggressive fungus able to cause fatal infections. All clinicians, microbiologists and pathologists need to be aware of these emerging mycoses as well as of the risks involved in medical practices, which may provoke serious fungal infections such as those produced byApophysomyces (AU)

Antecedentes: Los hongos mucorales son agentes emergentes causantes de infecciones cutáneas primarias presentes en forma de fascitis necrotizante. Objetivos: La finalidad de este estudio fue la de investigar una serie de infecciones sugestivas de fascitis necrotizante causadas por alguna de las especies de Apophysomyces a lo largo de un año en un hospital del norte de la India. Métodos: Se obtuvieron los datos de todos los pacientes con sospecha de fascistis necrotizante. Las biopsias de piel de la zona afectada fueron cultivadas en medios de cultivos estándar y se evaluaron histopatológicamente mediante tinciones convencionales y específicas para hongos. Los aislamientos de Apophysomyces fueron identificados morfológicamente y mediante la secuenciación del espaciador intergénico ribosomal (ITS). La sensibilidad antifúngica se determinó mediante el método EUCAST y la evolución de los pacientes fue monitorizada. Resultados: Se encontraron siete pacientes con fascitis necrotizante causada por especies de Apophysomyces. Seis aislamientos fueron identificados como Apophysomyces variabilis y uno como Apophysomyces elegans. Cinco pacientes habían recibido previamente inyecciones intramusculares en el área afectada. Tres pacientes se recuperaron, dos fallecieron y de los dos restantes no se tiene seguimiento médico, aunque presumiblemente fallecieron debido a que padecían enfermedades terminales. El posaconazol y la terbinafina fueron los compuestos más activos frente a A. variabilis, mientras que el único aislamiento deA. elegans fue resistente a todos los antifúngicos ensayados. Conclusiones: Se confirma que Apophysomyces es un hongo agresivo capaz de causar infecciones con desenlace fatal. Clínicos, microbiólogos y patólogos deben ser conscientes de los riesgos de estas micosis emergentes y de que determinadas prácticas médicas puedan provocar infecciones fúngicas graves como las producidas por Apophysomyces (AU)

Fungal necrotizing fasciitis, an emerging infectious disease caused by Apophysomyces (Mucorales).

BACKGROUND: The mucoralean fungi are emerging causative agents of primary cutaneous infections presenting in the form of necrotizing fasciitis. AIMS: The aim of this study was to investigate a series of suspected necrotizing fasciitis cases by Apophysomyces species over one-year period in a northern Indian hospital. METHODS: The clinical details of those patients suspected to suffer from fungal necrotizing fasciitis were recorded. Skin biopsies from local wounds were microscopically examined and fungal culturing was carried out on standard media. The histopathology was evaluated using conventional methods and special stains. Apophysomyces isolates were identified by their morphology and by molecular sequencing of the internal transcribed spacer (ITS) region of the ribosomal genes. Antifungal susceptibility testing was carried out following EUCAST guidelines and treatment progress was monitored. RESULTS: Seven patients were found to be suffering from necrotizing fasciitis caused by Apophysomyces spp. Six isolates were identified as Apophysomyces variabilis and one as Apophysomyces elegans. Five patients had previously received intramuscular injections in the affected area. Three patients recovered, two died and the other two left treatment against medical advice and are presumed to have died due to their terminal illnesses. Posaconazole and terbinafine were found to be the most active compounds against A. variabilis, while the isolate of A. elegans was resistant to all antifungals tested. CONCLUSIONS: Apophysomyces is confirmed as an aggressive fungus able to cause fatal infections. All clinicians, microbiologists and pathologists need to be aware of these emerging mycoses as well as of the risks involved in medical practices, which may provoke serious fungal infections such as those produced by Apophysomyces.

Health-care-associated infections: Risk factors and epidemiology from an intensive care unit in Northern India.

BACKGROUND AND AIMS: Health-care-associated infection is a key factor determining the clinical outcome among patients admitted in critical care areas. The objective of the study was to ascertain the epidemiology and risk factors of health-care-associated infections in Intensive Care Units (ICUs) in a tertiary care hospital. METHODS: This prospective, observational clinical study included patients admitted in ICU over a period of one and a half years. Routine surveillance of various health-care-associated infections such as catheter-associated urinary tract infections (CAUTI), central-line-associated blood stream infections (CLABSI), and ventilator-associated pneumonias (VAP) was done by the Department of Microbiology through specific Infection Surveillance Proforma. RESULTS: Out of 679 patients, 166 suffered 198 episodes of device-associated infections. The infections included CAUTI, CLABSI, and VAP. The number of urinary tract infection (UTI) episodes was found to be 73 (10.75%) among the ICU patients who had indwelling urinary catheter. In addition, for 1 year CAUTI was calculated as 9.08/1000 catheter days. The number of episodes of blood stream infection was 86 (13.50%) among ICU patients having central line catheters. Also, CLABSI was found to be 13.86/1000 central line days. A total of 39 episodes (6.15%) of VAP was found in ICU patients over 18 months and VAP present for 6.04/1000 ventilator days. CONCLUSIONS: The organisms most commonly associated with health-care-associated infections were Pseudomonas aeruginosa and Acinetobacter species. The risk factors identified as being significantly associated with device associated infections in our ICU were diabetes, COPD and ICU stay for ≥8 days (P < 0.05).

Determination of Extended-Spectrum ß-Lactamases and AmpC Production in Uropathogenic Isolates of Escherichia coli and Susceptibility to Fosfomycin.

BACKGROUND: Urinary tract infection due to Escherichia coli is one of the common problem in clinical practice. Various drug resistance mechanisms are making the bacteria resistant to higher group of drugs making the treatment options very limited. This study was undertaken to detect ESBLs and AmpC production in uropathogenic Escherichia coli isolates and to determine their antimicrobial susceptibility pattern with special reference to fosfomycin. MATERIALS AND METHODS: A total number of 150 E. coli isolates were studied. ESBL detection was done by double disc synergy and CLSI method. AmpC screening was done using cefoxitin disc and confirmation was done using cefoxitin/cefoxitin-boronic acid discs. In AmpC positive isolates, ESBLs was detected by modifying CLSI method using boronic acid. Antimicrobial susceptibility pattern was determined following CLSI guidelines. Fosfomycin susceptibility was determined by disc diffusion and E-test methods. RESULTS: ESBLs production was seen in 52.6% of isolates and AmpC production was seen in 8% of isolates. All AmpC producers were also found to be ESBLs positive. ESBLs positive isolates were found to be more drug resistant than ESBLs negative isolates. All the strains were found to be fosfomycin sensitive. CONCLUSIONS: ESBLs and AmpC producing isolates are becoming prevalent in E. coli isolates from community setting also. Amongst the oral drugs, no in-vitro resistance has been seen for fosfomycin making it a newer choice of drug (although not new) in future. An integrated approach to contain antimicrobial resistance should be actually the goal of present times.

Multiple subcutaneous cysts due to Exophiala spinifera in an immunocompetent patient.

Here we report a case of a 55-year-old Indian male presenting with multiple subcutaneous cysts, which developed from painful nodules at the dorsal right wrist joint. Subsequently a painful nodule appeared on the left knee joint. Cytological examination of the knee swelling revealed a suppurative inflammatory lesion consisting of neutrophils, lymphocytes, multinucleated giant cells and few fungal elements, without involvement of the overlying skin. Exophiala spinifera was cultured (CBS 125607) and its identity was confirmed by sequencing of the internal transcribed spacer (ITS rDNA). The cysts were excised surgically, without need of additional antifungal therapy. There was no relapse during one-year follow-up and the patient was cured successfully. In vitro antifungal susceptibility testing showed that posaconazole (0.063 µg/ml) and itraconazole (0.125 µg/ml) had the highest and caspofungin (4 µg/ml) and anidulafungin (2 µg/ml) the lowest activity against this isolate. However, their clinical effectiveness in the treatment of E. spinifera infections remains to be evaluated. In this case report, we have also compiled cases of human E. spinifera mycoses which have been reported so far.

Fatal cerebral phaeohyphomycosis in an immunocompetent individual due to Thielavia subthermophila.

We report the first case of fatal brain infection in an Indian farmer caused by Thielavia subthermophila, a dematiaceous thermophilic fungus in the order Sordariales, and present a review of previous infections from this order. The patient failed amphotericin B therapy combined with surgical excision despite the drug's low MICs in vitro.