[Mucormycosis in paranasal sinuses]. / Mucormykosen der Nasennebenhöhlen.

Three patients with mucormycosis of the paranasal sinuses were treated in the University ENT departments in Bochum and Essen in recent years. All patients were immunocompromised for different reasons and had reduced resistance against microorganism infection. They presented with symptoms of orbital complications of sinusitis. The further progress of these life-threatening fungal infections with a mortality rate between 35 and 70% depends on early and definitive diagnosis and radical surgical therapy to reduce the amount of infectious agent. The difficulties of early diagnosis by imaging, histology, microbiology, or molecular biology and postoperative therapeutic options especially with amphotericin B, liposomal amphotericin B, and posaconazole are illustrated and discussed.

Caspofungin as second-line therapy for fever of unknown origin or invasive fungal infection following allogeneic stem cell transplantation.

Caspofungin (CAS) is the first of a new class of antifungal agents, the echinocandins, that interfere with fungal cell wall synthesis by inhibition of glucan synthesis. Here, we report the results of 31 patients treated with CAS following allogeneic SCT. CAS was administered as a second-line agent to patients with invasive fungal infection (IFI) (n=15) or fever of unknown origin (n=16) who were recalcitrant to or intolerant of prior antifungal therapy. Unsuccessful first-line regimes included amphotericin B (n=17), liposomal amphotericin B (n=5), fluconazole (n=3), itraconazole (n=1), and voriconazole (n=2). All patients received concomitant immunosuppressive therapy for graft-versus-host disease. In 23 patients, cyclosporin A (CSA) and CAS were administered concurrently without any major side effects detected. Observed increases in GPT were not clinically significant. Normalization of serum creatinine and significant reductions in C-reactive protein were observed in response to CAS. Favorable outcome to CAS were documented in eight of 15 patients with IFI and in 15 of 16 patients with fever of unknown origin. CAS is a promising alternative in patients with IFI and fever of unknown origin in the setting of allogeneic SCT.

Isolation and antimicrobial susceptibility testing of fecal strains of the archaeon Methanobrevibacter smithii.

BACKGROUND: The archaeon Methanobrevibacter smithii is regarded as part of the indigenous microflora of the human intestine but may be connected with pathological conditions. The microbe is extremely oxygen intolerant and is not detectable by anaerobic culture techniques for bacteria. Accordingly, to date quantitative antimicrobial susceptibility data of human isolates are missing. METHODS: The anoxic Hungate technique and a three-step culture procedure using media supplemented with antibiotics were applied to isolate M. smithii from randomly selected human feces. The minimum inhibitory concentrations (MICs) of 15 isolates and the reference strain DSM 861 were determined using a broth macrodilution test resembling the procedure for testing anaerobic bacteria. RESULTS: The 16 strains were highly resistant (MICs >64 mg/l) against penicillin G, cephalothin, vancomycin, streptomycin, gentamicin, ciprofloxacin, and clindamycin. Metronidazole inhibited the strains at MICs between 0.5 and 64 mg/l. CONCLUSIONS: Multiple-antibiotic-resistant Methanoarchaea occur in the human gut. They may be selected during therapy with common antibacterial agents and may be eliminated by the application of metronidazole.

Fungal colonization and invasive fungal infections following allogeneic BMT using metronidazole, ciprofloxacin and fluconazole or ciprofloxacin and fluconazole as intestinal decontamination.

Invasive fungal infections (IFI) are increasingly diagnosed in patients undergoing allogeneic BMT. We have previously shown that the addition of metronidazole to ciprofloxacin for gastrointestinal bacterial decontamination significantly reduces the incidence of grades II-IV aGVHD by reduction of the anaerobic intestinal bacterial flora. Here, we found that the combined use of ciprofloxacin, metronidazole and fluconazole as antifungal prophylaxis increased intestinal yeast colonization when compared to ciprofloxacin and fluconazole alone (P < 0.01). Based on the EORTC criteria, a total of 18 out of 134 study patients developed IFI: seven of 68 (10%) patients who received metronidazole compared to 11 of the 66 (17%) patients decontaminated without metronidazole developed IFI (log-rank P = 0.36). Lethal IFI occurred in two of seven patients receiving metronidazole and in four of 11 patients without anaerobic decontamination. In conclusion, bacterial intestinal decontamination using metronidazole as an antibiotic with activity against most anaerobic intestinal bacteria significantly increases the intestinal yeast burden without influencing the incidence of IFI in patients undergoing allogeneic BMT.

A comparison of methods of phenotypic and genotypic fingerprinting of Exophiala dermatitidis isolated from sputum samples of patients with cystic fibrosis.

Phenotypic and genotypic characteristics of 11 strains of Exophiala dermatitidis were investigated. Ten strains (including three reference strains) were isolated from sputum samples of six patients with cystic fibrosis (CF) in Germany, and one reference strain was isolated from a patient with phaeohyphomycosis in Japan. The strains showed differences in their ability to assimilate sorbitol, palatinose, rhamnose, gluconate and melezitose, leading to the differentiation of seven auxotypes. The IC30 of amphotericin B, and ketoconazole and itraconazole, respectively, indicated susceptibility, whereas the IC30 of fluconazole and 5-fluorocytosine indicated resistance in all strains. Protein patterns in SDS-PAGE revealed no major differences. The glycoconjugate patterns distinguished the Japanese strain from the other strains. Cluster analysis of whole-cell fatty acid methyl ester (FAME) profiles with the Microbial Identification System (MIS) revealed two major clusters separating a reference strain and the Japanese strain from the other strains. Analysis of patterns resulting from random amplification of polymorphic DNA (RAPD) with two arbitrary primers showed four genotypes. Comparison of the results revealed no agreement between the different fingerprinting methods, except the separation of the Japanese strain from the European CF strains. As the results of assimilation tests seem to vary between different laboratories, the analysis of FAME profiles and RAPD analysis are recommended for typing E. dermatitidis.

Serum level determination of fluconazole by high-performance liquid chromatography and bioassay.

An HPLC method using a reverse phase system, an isocratic mobile phase and 1-phenyl-1,2 ethanediol as internal standard and a well diffusion bioassay using a strain of Candida pseudotropicalis were compared for the measurement of fluconazole in serum. Both methods permit determination of fluconazole in the range from 1 mg/L to 30 mg/L. The correlation between both methods was found to be r = 0.89. Both methods are useful for monitoring the serum level of fluconazole in clinical routine work.

Use of phenotypic and genotypic fingerprinting methods in the strain identification of Aspergillus fumigatus.

Aspergillus fumigatus isolates (n = 6) from a lung transplant recipient, one isolate from a patient who had been on the same ward and a reference strain (NCPF 2140) were compared using three typing methods: SDS-PAGE, immunoblotting with serum from the transplant patient and random amplified polymorphic DNA (RAPD) assay. Neither the SDS-PAGE, immunoblot nor RAPD assay with single primers revealed differences between the eight isolates. Digestion of one primer product with the endonuclease EcoRI discriminated between the six patient isolates and the other two strains. The RAPD assay using pairwise combined primers showed identical patterns for the patient's strains but differentiated between the two other strains. It is concluded that any single technique may fail to detect strain differences and that a spectrum of typing methods is necessary in order to reveal or to exclude cross-infections with Aspergillus fumigatus.

Determination of itraconazole and hydroxy-itraconazole in sera using high-performance-liquid-chromatography and a bioassay.

The concentrations of itraconazole and its active metabolite, hydroxy-itraconazole, were determined in the sera of 49 patients having received itraconazole for therapeutic or prophylactic purposes. Measurements by HPLC were compared with a biological assay using a strain of Paecilomyces variotii as test organism and itraconazole as standard. The concentration of hydroxy-itraconazole in serum was on average 1.6 times higher than the concentration of itraconazole. The sum of itraconazole and hydroxy-itraconazole concentrations determined by HPLC showed a linear relationship with the concentrations obtained by the bioassay (r = 0.94). The biological method gives approximately 20% higher values than the HPLC method indicating that hydroxy-itraconazole is biologically more active than itraconazole. As the values of the Paecilomyces variotii bioassay are in the same range as the HPLC measurements, it is concluded that both methods are suitable for the monitoring of itraconazole medication.

In vitro susceptibility of fungal isolates of clinically important specimens to itraconazole, fluconazole and amphotericin B.

The in vitro activity of itraconazole, fluconazole and amphotericin B was tested against 207 yeast strains and 3 Aspergillus fumigatus strains isolated from blood. The other 42 A. fumigatus strains were selected from respiratory tract infections. A microdilution method was employed to determine the inhibitory concentrations to restrain 70% of isolate growth (IC30). The inhibition concentrations of amphotericin B are all around the value 0.25 mg/l with a deviation of two concentration degrees, indicating sensitivity of all strains. The test results of itraconazole showed the majority of strains in the range of sensitivity (200 isolates) and low sensitivity (44 isolates). Five of 19 Candida glabrata strains demonstrated resistance to itraconazole. The results of fluconazole showed a good sensibility of C. albicans, but 4.5% of strains were resistant. Low sensitivity (1 strain) and resistance (24 strains) were evaluated for C. glabrata and C. krusei isolates. No strain of A. fumigatus was inhibited by fluconazole. The data show the necessity of in vitro tests.

Comparison of high-performance liquid chromatography and bioassay of amphotericin B in serum.

For the determination of amphotericin B in serum a high-performance liquid chromatography (HPLC) method using simple protein precipitation and an isocratic mobile phase as well as a plate diffusion bioassay are described. Using 5-fluorocytosine-resistant strain of Candida albicans and peptone in medium as an antagonist of 5-fluorocytosine allows simple measurement of amphotericin B both in the absence and in the presence of 5-fluorocytosine. The correlation coefficient (r) between bioassay and HPLC runs is 0.88. Generally, the biological determination gives slightly higher values of amphotericin B than the HPLC method. Both methods are useful for amphotericin B drug monitoring.

A rare zygomycosis due to Cunninghamella bertholletiae.

An unusual endobronchial zygomycosis due to Cunninghamella bertholletiae in a leukaemic patient is reported. Following bypass operation, fungal infection developed. The patient died on day 7 after surgery as a result of long-term immunosuppressive treatment and haemodynamic complications.

Prophylaxis and treatment of fungal infections with fluconazole in bone marrow transplant patients.

In an open study 31 patients undergoing bone marrow transplantation for various haematological diseases received fluconazole as prophylaxis or treatment of fungal infections. In 26 of these patients an antecedent oral prophylaxis with polyene antimycotics had failed to prevent infections with Candida species. Five of the 31 patients received fluconazole as primary prophylaxis because of non-compliance for polyene antimycotics. Fluconazole was administered orally at a daily dose of 100 mg and 200 mg, respectively (n = 29), or intravenously at a dose of 100 mg and 400 mg (n = 2). Cure or efficient prophylaxis was achieved in 22/31 patients (71%) after a median of 52 (9 to 493+) treatment days. In three patients (10%) Candida was eradicated but the infection reappeared 14-28 days after cessation of the drug; in 6 patients (20%) the infection was persistent or progressive. Four patients developed lethal Aspergillus infection while on fluconazole medication. A moderate and reversible elevation of liver function tests under therapy was observed in 9 patients and was possibly attributable to fluconazole in three of them (10%). One patient developed tremor which resolved after cessation of fluconazole. No other adverse drug reactions could be noted. We conclude that fluconazole is a relatively safe and effective drug for the prevention and treatment of superficial and, possibly, deep Candida infections in severely immunocompromised patients. However, it is presumably without preventive value in Aspergillus infections.

In vitro susceptibility of yeast isolates from the blood to fluconazole and amphotericin B.

221 yeast strains including 131 of Candida albicans, 21 of C. tropicals, 23 of C. parapsilosis, 19 of C. glabrata, 7 of C. guilliermondii, 6 of C. krusei and of other species were isolated from the blood. The activity of fluconazole and amphotericin B was investigated by means of a photometer-read broth microdilution method measuring the 30% inhibitory concentrations (IC30). The results of fluconazole showed a higher susceptibility of C. albicans compared to the other species. However, 6 (4.5%) resistant strains of C. albicans were found. Low sensitivity and resistance were evaluated for C. krusei and C. glabrata strains. All isolates showed susceptibility to amphotericin B.

[Zygomycoses: clinical aspects and pathology in 10 patients]. / Zygomykosen: Klinik und Pathologie bei 10 Patienten.

Deep fungal infections caused by zygomycetes (so-called mucormycoses) are rare. Whereas in the past rhinocerebral mycosis dominated, today a wide range of clinical manifestations must be expected, especially pulmonary infections and invasion of vessel walls with systemic infarction. On the basis of 10 cases of Mucoraceae mycosis and a review of the literature, the predisposing conditions, clinical symptoms and pathologic-anatomic findings are described. Our observations include 7 patients with leukemia and 2 adults and one newborn without malignant neoplasia. Except for the patient with rhinocerebral mycosis, the diagnosis was not established during the patients' lifetime. 3 patients received systemic antimycotic therapy. Our observations suggest that infarctions of internal organs in immunocompromised patients should direct suspicion towards angio-related mycoses, not only of aspergillosis, but also of zygomycosis.

[Prophylaxis and therapy of fungal infections with fluconazole in patients after bone marrow transplantation]. / Prophylaxe und Therapie von Pilzinfektionen mit Fluconazol bei Patienten nach Knochenmarktransplantation.

In an open study 31 patients undergoing bone marrow transplantation for various haematological diseases received fluconazole as prophylaxis or treatment of fungal infections. In 26 of these patients an antecedent oral prophylaxis with polyene antimycotics had failed to prevent infections with Candida species. Five of the 31 patients received fluconazole as primary prophylaxis because of non-compliance for polyene antimycotics. Fluconazole was administered orally at a daily dose of 100 mg and 200 mg, respectively (n = 29), or intravenously at a dose of 100 mg and 400 mg (n = 2). Cure or efficient prophylaxis was achieved in 22/31 patients (71%) after a median of 52 (9 to 546+) treatment days. In three patients (10%) Candida was eradicated but the infection reappeared 14-28 days after cessation of the drug; in 6 patients (20%) the infection was persistent or progressive. Four patients developed lethal Aspergillus infection while on fluconazole medication. A moderate and reversible elevation of liver function tests under therapy was observed in 9 patients and was possibly attributable to fluconazole in 3 of them (10%). One patient developed tremor which resolved after cessation of fluconazole. No other adverse drug reactions could be noted. We conclude that fluconazole is a relatively safe and effective drug for the prevention and treatment of superficial and, possibly, deep Candida infections in severely immunocompromised patients. It is presumably without preventive value in Aspergillus infections.