Invasive cerebral aspergillosis in non-neutropenic patients: A case series from Western India.

PURPOSE: Invasive cerebral aspergillosis (ICA) is a rare but fatal infection affecting neutropenic immunocompromised patients. Recently cases have been reported in non-neutropenic settings also. We hereby present a series of ICA cases in non-neutropenic patients diagnosed at our tertiary care centre in Western India between March to October 2021. METHODS: All patients with clinico-radiological suspicion of CNS infections were analysed. Data regarding Clinico-radiological features, diagnosis, treatment and outcome were collected. After ruling out bacterial, viral and mycobacterial causes, appropriate samples were sent for KOH (potassium hydroxide) wet mount, fungal culture, histopathology and serum/CSF galactomannan. RESULTS: A total of four patients were diagnosed with ICA with a mean age of 43.5 years. Three patients had significant comorbidities; Diabetes mellitus, chronic liver disease and COVID-19 pneumonia treated with dexamethasone, respectively. One patient had no known predisposing factor. Radiologically, one patient presented with a frontal brain abscess and two patients had multiple subcortical hyperintensities. Three patients were diagnosed based on CSF galactomannan (Platelia™ Aspergillus antigen, Bio-Rad, France) with OD >1 and one patient had high serum galactomannan (OD >2). CSF culture grew Aspergillus species in two patients. All patients were treated with Voriconazole. One patient recovered, and the remaining three succumbed due to delayed presentation and extensive cerebral involvement. CONCLUSION: Even in non-neutropenic patients, a high index of suspicion is warranted for cerebral aspergillosis. CSF galactomannan can be considered a reliable marker for diagnosing ICA in non-neutropenic settings. Early diagnosis allows timely antifungal therapy, which could be a key to improving the outcomes.

Prosthetic valve endocarditis due to Candida parapsilosis - a rare case report.

Fungal endocarditis is a rare and fatal condition, most frequently caused by species of the genera Candida and Aspergillus. Fever and changing heart murmur are the most common clinical manifestations. The diagnosis of fungal endocarditis is challenging, with prosthetic valve endocarditis being extremely difficult to diagnose. The optimal management of the condition still remains debatable. We present a case of prosthetic valve endocarditis caused by Candida parapsilosis, managed empirically with liposomal amphotericin B, which was later shifted to combination therapy with high-dose echinocandin and fluconazole, but had a fatal outcome because the patient could not undergo timely surgical intervention. Treating C. parapsilosis endocarditis cases is difficult because of their biofilm production on native and prosthetic heart valves. A combined approach consisting of a high index of clinical suspicion, early diagnosis using serological markers followed by culture or PCR and prompt initiation of appropriate antifungals may aid in improving outcomes.

Prevalence, Presentation and Outcome of Secondary Bloodstream Infections among COVID-19 Patients.

BACKGROUND: The higher mortality rate in COVID-19 patients is still a concern. Though some studies mention that elderly patients with co-morbidities are at higher risk of mortality, some others report uneventful outcomes in young patients even without co-morbidities. Secondary bacterial and fungal infections, especially with nosocomial pathogens are known to be associated with worse outcome in the ongoing pandemic as well as in the previous viral outbreaks. In such a scenario, the outcome of hospitalized COVID-19 patients can be improved by timely identification of secondary infections using appropriate biomarkers and by following appropriate infection control measures to prevent the spread of nosocomial pathogens. OBJECTIVE: The study aims to find out the prevalence of bloodstream infections (BSI) among hospitalized COVID-19 patients and to analyze their laboratory markers and outcome by comparing them with those without BSI. METHODS: In this descriptive cross-sectional study, the prevalence of secondary BSI was determined among the hospitalized COVID-19 patients by including 388 blood culture bottles collected from 293 patients, which were received in the microbiology lab within the study period. RESULTS: The overall prevalence of BSI in COVID-19 patients was 39.5% (116/293), out of which 35.5% (104/293) infections were bacterial, and 4.1% (12/293) were fungal, while 8.9% (26/293) patients grew contaminants, and 51.5% (151/293) were sterile. Common causative agents of secondary BSI were found to be MDR Klebsiella pneumoniae (10.9%) and Acinetobacter baumannii (8.8%) followed by Candida species (4.1%). Patients with co-morbidities like diabetes, hypertension and COPD were at higher risk of developing BSI with significantly higher levels of sepsis markers such as Creactive protein (CRP), procalcitonin, ferritin and Interleukin-6 (IL-6). The mortality rate was significantly higher (60.2%) in patients with BSI compared to the group of patients without BSI. CONCLUSION: Our findings suggest the necessity of early diagnosis of the secondary infections using appropriate biomarkers and following proper infection control measures to prevent the spread of the nosocomial infections and improve the outcome of hospitalized COVID-19 patients.

Evaluation of MALDI-TOF MS for Identification of Species in the Candida parapsilosis Complex from Candidiasis Cases.

BACKGROUND: Phenotypically identified Candida parapsilosis is actually a complex of 3 member species named Candida parapsilosis sensu stricto (CPSS), Candida orthopsilosis (CO), and Candida metapsilosis (CM), which can be identified only by molecular methods and automated methods such as MALDI-TOF mass spectrometry (MS). This study was undertaken to evaluate the VITEK MS, which uses the principle of MALDI-TOF MS for the identification of member species of C. parapsilosis complex (CPC). METHODS: In this cross-sectional study, 126 presumptively identified and stocked isolates of CPC were included. Definite identification to species level was done by VITEK MS and PCR as the gold standard method. Clinico-demographic characters and risk factors were analyzed. Antifungal susceptibility testing was performed for fluconazole and voriconazole. RESULTS: Twelve isolates were not identified as CPC either by VITEK MS or PCR and hence were excluded from the analysis. Out of 114 CPC isolates, 89 (78.1%), 18 (15.8%), and 7 (6.1%) isolates were identified as CPSS, CO, and CM, respectively, by VITEK MS. PCR identified 84 (79.2%), 15 (14.2%), and 7 (6.6%) isolates as CPSS, CO, and CM, respectively. However, PCR did not detect 8 isolates of CPSS detected by VITEK MS. VITEK MS showed 95.3% agreement in species identification and showed a kappa coefficient of 0.87, which is almost perfect agreement. Predominant isolations of all 3 species were from blood. Resistance was observed more in CPSS for both the azoles. CONCLUSION: MALDI-TOF MS can be used as a rapid, reliable, cost-effective method to identify the species of CPC.

Clinical features, diagnosis and treatment outcome of fungal endocarditis: A systematic review of reported cases.

The landscape of fungal endocarditis (FE) has constantly been evolving in the last few decades. Despite the advancement in diagnostic methods and the introduction of newer antifungals, mortality remains high in FE. This systematic review aimed to evaluate the epidemiology, clinical features, diagnostic and therapeutic interventions in patients with FE. We also aim to examine the aforementioned factors as a determinant of mortality in FE. A literature search was performed in PubMed, Google Scholar and Scopus, and all patients ≥18 years with proven fungal endocarditis were included. A total of 220 articles (250 patients) were included in the final analysis. Candida was the commonest aetiology (49.6%), followed by Aspergillus (30%) and Scedosporium species (3.2%). The proportion of prosthetic valve endocarditis (PVE) and intravenous drug users was 35.2% and 16%, respectively. The overall mortality rate was 40%. On multivariate analysis, Aspergillus endocarditis (HR 3.7, 95% CI 1.4-9.7; p = .009) and immunocompromised state (HR 2.8, 95% CI 1.24-6.3; p = .013) were independently associated with mortality. Patients treated with surgery along antifungals had better survival (HR 0.20, 95% CI 0.09-0.42; p < .001) compared to those treated with antifungals alone. Recurrence of FE was reported in 10.4% of patients. In conclusion, FE carries significant mortality, particularly in immunodeficient and Aspergillus endocarditis. We advocate the use of surgery combined with antifungals to improve clinical outcomes.

New-onset hyperglycaemia and prolonged systemic corticosteroids therapy in mild COVID-19 patients as major risk factors for invasive mucormycosis: a preliminary study.

Background and Purpose: Rapid surge of invasive mucormycosis has surprised the Indian healthcare system amidst the coronavirus disease-19 (COVID-19) pandemic. Hence, there is an urgent need to find the risk factors for the sudden rise in cases of invasive mucormycosis among COVID-19 patients. This study aimed to find crucial risk factors for the sudden surge of invasive mucormycosis in India. Materials and Methods: This case-control study included 77 cases of COVID-19 associated mucormycosis (CAM) who matched the controls (45 controls) in terms of age , gender, and COVID-19 disease severity. The control group included subjects that matched controls without mucormycosis confirmed by reverse transcription-polymerase chain reaction at our tertiary care center during April-May 2021. Probable predisposing factors, such as duration of diabetes mellitus (DM), history of recent hospitalization, duration of hospital stay, mode of the received oxygen supplementation, and use of steroids, zinc, vitamin c, and any other specific drugs were collected and compared between the two groups. Moreover, the laboratory parameters, like glycated hemoglobin (HbA1c), highly sensitive C-reactive protein (hs-CRP), and erythrocyte sedimentation rate (ESR) were analyzed to find out the significant association with CAM. Results: DM (Odds ratio=7.7, 95% CI 3.30-18.12; P=<0.0001) and high glycated hemoglobin level (HbA1c>7.5 gm %) (odds ratio=6.2, 95% CI 1.4-26.7; P=0.014) were significant risk factors for the development of invasive mucormycosis among the COVID-19 cases. A higher number of mild COVID-19 cases developed CAM, compared to the moderate to severe cases (59.7% vs 40.3%). Use of systemic corticosteroids (odd ratio=5 with 95% CI 1.5-16.9; P=0.007) was found to be a risk factor for invasive mucormycosis only in mild COVID-19 cases. Use of oxygen, zinc, and vitamin C supplementation, and proprietary medicine did not lead to a significant risk of invasive mucormycosis in cases, compared to controls. Cases with invasive mucormycosis had a higher level of inflammatory markers (hs-CRP and ESR, P=<0.001 and 0.002, respectively), compared to the controls. Conclusion: Uncontrolled and new-onset DM and the use of systemic corticosteroids in mild cases were significantly associated with a higher risk of invasive mucormycosis in COVID-19 cases. There should be a strong recommendation against the use of systemic corticosteroids in mild COVID-19 cases.

Intracranial abscess due to Prevotella bivia: First case report from India.

The association of Prevotella bivia (P. bivia), a Gram negative obligate anaerobic bacillus with brain abscess has been rarely reported. We hereby, report a case of brain abscess in a 50-year-old man, who suffered a head trauma followed by decompression surgery 10 months ago. Aspirated pus sample grew Methicillin resistant Staphylococcus aureus (MRSA) and P. bivia sensitive to metronidazole. The patient recovered well after a brain abscess evacuation surgery and post-operative metronidazole therapy, confirming the pathogenic role of P. bivia in this case.