Allergic bronchopulmonary mycosis in patients with asthma: period prevalence at a university hospital in Saudi Arabia.

Allergic bronchopulmonary mycosis (ABPM) is a known complication of asthma and can result in progressive lung damage, respiratory failure and death. Asthma is a common disease in Saudi Arabia and until now the prevalence of ABPM has not been investigated. The aim of this study was to estimate the period prevalence of ABPM due to Aspergillus and Candida in patients with asthma. The setting was an outpatient pulmonary clinic at a university hospital in the central region of Saudi Arabia. Two hundred and sixty-four consecutive patients with asthma (150 or 57% females) were evaluated. All patients were screened for ABPM with skin prick test (SPT) using a panel of fungal antigens. Those with positive skin reactions had further clinical, immunological, respiratory and radiological assessment. ABPM was diagnosed by the presence of a minimum of five of the major criteria suggested by Rosenberg in 1977. Of the 264 patients, 62 (23%) had a positive SPT for at least one fungal allergen, of whom 44 (71%) were females (P=0.01). Seven patients (six females) were diagnosed with ABPM due to Aspergillus and (or) Candida species. Therefore, we estimate the period prevalence of ABPM to be 2.7% (95% confidence interval 1.3-5.4%). A. niger was the commonest fungal species isolated in our group. In conclusion, ABPM is not uncommon in Saudi Arabia and females seem to be more at risk. Because asthma is common, physicians need to have high index of suspicion for this disease and pursue the diagnosis with the appropriate tests.

Cavitating pneumonia due to Trichosporon beigelii in a patient with acute myeloid leukaemia.

A 21-year-old man with acute myeloid leukaemia developed cavitating pneumonia while neutropenic and on broad spectrum antibiotics following induction chemotherapy. Trichosporon beigelii was isolated from several samples of sputum. He was successfully treated with amphotericin B. Previous reports of lung infection with this organism are reviewed.

The medically important yeasts present in clinical specimens.

In an effort to determine the yeast species present in clinical specimens obtained from patients attending a busy Saudi hospital, the present study was undertaken. More than 1614 yeasts were isolated in culture from pathologic specimens of over 1303 patients with diverse clinical conditions. Organisms identified in 22 species of eight general included: Candida albicans, C. parapsilosis, C. tropicalis, C. krusei, C. lipolytica, C. guilliermondii, C. pseudotropicalis, C. pinotolopesii, C. humicola, C. stellatoidea, C. lusitaniae, Torulopsis glabrata, T. inconspicua, T. candida, Trichosporon beigelii, T. capitatum, Saccharomyces cerevisiae, Cryptococcus neoformans, C. albidus, Rhodotorula glutinis, Hansenula anomala and Prototheca zopfii. The details of specimen types yielding these yeasts in culture are presented in the text. The most frequently isolated yeasts was C. albicans, followed by T. glabrata, C. parapsolosis, C. tropicalis, T. inconspicua, C. krusei, S. cerevisiae, T. candida, and T. beigelii. Twenty isolates of six species were recovered from blood of which C. albicans was also the most common. Crytococcus neoformans was found causing cryptococcal meningitis being isolated from the CSF on an 8-year-old female patient. Future studied assessing the incidence of yeast infections in each homogeneous group of patients are recommended.

Comparison of phospholipase and proteinase activity in Candida albicans and C. dubliniensis.

Although the production of virulence enzymes by Candida albicans has been extensively explored, little attention has been given to the virulence factors of C. dubliniensis. In the present study, an attempt was made to investigate phospholipase activity (Pz value) and secretory aspartyl proteinase production of C. dubliniensis and compare it with C. albicans. None of the 87 C. dubliniensis isolates tested, produced phosholipases whereas, in contrast all the 52 (100%) C. albicans isolates tested demonstrated varying degree of phospholipase activity (Pz value: 0.37-0.74), with 35 (67.3%) of them eliciting a higher phospholipase activity (Pz values between 0.37 and 0.50). Only 32% of the C. dubliniensis isolates exhibited moderate activity (score of 1+) of secretory aspartyl proteinase whereas a vast majority (68%) of them were non-proteolytic. On the contrary, a strong proteinase activity (score of 2+) was observed for 79% of C. albicans while the remaining 21% isolates showed moderate proteinase activity (score of 1+). As phospholipases and aspartyl proteinases of C. albicans are considered important virulence factors, the absence or lowered expression of these enzymes in C. dubliniensis may indicate the less virulent nature of this novel yeast species when compared with C. albicans.

First report of human infection due to the fungus Triadelphia pulvinata.

Triadelphia pulvinata, a soil hyphomycete, was found to be the cause of eczematoid, scaly, grey lesions on the skin of both eyelids of a 30-year-old Indian male living in Saudi Arabia. Repeated KOH preparations of the skin scrapings showed presence of sclerotic, branched, septate hyphae. When cultured, skin scrapings from the lesion grew the dematiaceous fungus T. pulvinata. Treatment with topical clotrimazole cured the infection, and no recurrence of the infection was noted in a 5-year follow-up.

Prevalence of Candida tropicalis in clinical specimens from patients with variable clinical syndromes over a 5-year period.

In this study, we have examined our records for the isolation of Candida tropicalis from clinical specimens of patients with heterogeneous clinical presentations during the past 5 years. We have found that this species ranks third among all yeasts in frequency of isolation from clinical specimens and that the trend of recovery from the specimens is rising over the years. The isolation rate of C. tropicalis was highest from urine specimens (36%) followed by respiratory specimens (22%). The frequency of isolation of C. tropicalis from vaginal specimens was relatively high (14%), however the trend was declining over the years. In general, the high recovery of Candida tropicalis from clinical specimens of patients with variable disease supports the views of this organism being a major pathogen.

Identification of chlamydospore-negative Candida albicans using CHROMagar Candida medium.

This study was undertaken to evaluate the utility of CHROMagar Candida medium for the identification of chlamydospore-negative Candida albicans. A total of 60 isolates including 45 chlamydospore-negative C. albicans, 10 chlamydospore-positive C. albicans (positive controls) and five non-C. albicans (negative controls) were investigated. On the basis of germ tube test, assimilation of trehalose (Tre), glucosamine (GlcN), N-acetyl glucosamine (GlcNAc), secretory aspartyl production and serotyping, the 45 chlamydospore-negative C. albicans isolates were assigned to the reported three groups. Eighteen isolates showing positive germ tube test, negative for the assimilation of Tre, GlcN/GlcNAc, strong producers of proteinase (2+) and assigned to serotype B belonged to group I. Whereas, the isolates in group II and group III showed common characteristics including assimilation of Tre, GlcN/GlcNAc, moderate production of proteinase (1+) and were serotype A, except for the fact that group II isolates were germ tube positive and group III isolates were negative. Using CHROMagar Candida medium, all the 45 chlamydospore-negative and 10 positive control isolates were accurately identified on the basis of characteristic green color at 37 degrees C for 48 h of incubation. On the other hand at an optimum incubation temperature of 37 degrees C none of the non-C. albicans (negative controls) showed characteristic green color thus yielding a 100% sensitivity and specificity. Isolates in group-I showed a slow growth rate and no visible growth was observed at 24 h, whereas, groups II, III and the control isolates showed visible growth at 24 h. Besides differences in growth rates, these isolates also varied in their characteristic colony color which gradually changed over a period of time. The results of this study clearly suggest that CHROMagar Candida medium is not only a simple, reliable and cost effective method for the identification of chlamydospore-negative atypical C. albicans, but can also be used to differentiate various groups of chlamydospore-negative C. albicans.

Recovery and studies on chlamydospore-negative Candida albicans isolated from clinical specimens.

During a period of 31 months, we isolated 3525 strains of Candida albicans from different patient specimens. Twenty-five of these (0.71%), obtained from female patients, displayed morphological and biochemical characteristics different from those seen in typical C. albicans. The failure to produce chlamydospores in cornmeal agar was the common denominator in this group. The strains were categorized into three groups: Group I contained 13 isolates that produced germ tubes but were unable to assimilate trehalose (TRE), glucosamine (GLN) and N-acetylglucosamine (NAG); Group II contained four isolates that were germ-tube positive and able to assimilate TRE, GLN and NAG; and Group III contained eight isolates that were germ-tube negative and able to assimilate TRE, GLN and NAG. These isolates were further studied to determine their biotypes, serotypes, extracellular proteinase production and antifungal susceptibility. Group I isolates were of serotype B, whereas Groups II and III were serotype A. All isolates produced high to moderate amounts of extracellular proteinase. Six group I isolates were resistant to 5-fluorocytosine, whereas all groups II and III isolates were susceptible to this drug. Five of the 12 isolates of group II and III were resistant to fluconazole, itraconazole and ketoconazole.

Exophiala jeanselmei keratitis.

We present the case of a 42-year-old Saudi male with a fungal corneal abscess in his left eye. The aetiological agent was found to be the dematiaceous fungus Exophiala jeanselmei. The patient was treated with topical natamycin, miconazole, and also amphotericin B. During the course of the infection corneal perforation occurred which was treated with cyanocrylate glue. Secondary glaucoma resulted from peripheral anterior synechia which necessitated trabeculectomy. At the end of the course the infection was successfully eradicated, the complications were cured, and vision improved from counting fingers in front of the face at presentation to 20/80. There was no recurrence of the infection in a follow-up period of 2 years.

Candida dubliniensis at a university hospital in Saudi Arabia.

Candida dubliniensis is a newly described yeast species that is a close phylogenetic relative of C. albicans. Although it has been reported from different parts of the world, no detailed investigation of this species has been done in Saudi Arabia. The purpose of the present study was to identify C. dubliniensis isolates recovered from clinical specimens at a tertiary-care hospital in Riyadh, Saudi Arabia, and to determine the drug susceptibility profiles of those isolates. Over a period of 8 months, 823 germ tube- and chlamydospore-positive yeasts identified as C. albicans and recovered from different clinical specimens were screened for their ability to grow at 45 degrees C on Sabouraud dextrose agar. Isolates which failed to grow at 45 degrees C were presumptively identified as C. dubliniensis. The species identities were further confirmed by the production of pseudohyphae and chlamydospores on Staib agar and their inability to assimilate D-xylose and alpha-methyl-D-glucoside by using the API 20C AUX system. A total of 27 (3.3%) isolates were identified as C. dubliniensis. They were all recovered from 23 human immunodeficiency virus-negative patients. The prevalence of C. dublinensis in bronchoalveolar lavage (33.3%), oral (16.7%), and blood (16.7%) specimens was high. In addition, 33 isolates previously identified as C. albicans and preserved among our stock blood culture isolates were also recruited for the study. Of these, 5 isolates were found to be C. dubliniensis, thus making the total number of isolates identified as this species 32. Antifungal susceptibility testing of the C. dubliniensis isolates showed 100% sensitivity to amphotericin B, 97% sensitivity to each of fluconazole and ketoconazole, and 87.5% sensitivity to itraconazole. However, in contrast to other studies, the majority of the isolates (65.6%) showed high levels of resistance to flucytosine (MIC > 64 microg/ml). Further studies are warranted to investigate the cause of this unusually high rate of resistance to flucytosine of the C. dubliniensis isolates in this region.

Actinomycotic brain abscess successfully treated by burr hole aspiration and short course antimicrobial therapy.

Three cases of brain abscess caused by Actinomyces israelii are reported which were successfully treated by burr hole aspiration and a short course of antibiotics (3-4 weeks). The clinical response of the patients, as well as the serial serum C-reactive protein levels and CT findings were used as a guideline for stopping antimicrobial therapy relatively early.

Cerebral phaeohyphomycosis caused by Fonsecaea pedrosoi in Saudi Arabia.

A case of cerebral phaeohyphomycosis (CPM) in a 70-yr-old Saudi male was diagnosed recently at King Khalid University Hospital in Riyadh. Computerized tomography (CT) scans of the patient's brain unveiled 2 abscesses in the left frontal and a 3rd abscess in the right frontal lobes. Aspirated pus from the abscesses contained branched, septate, brown hyphae diagnostic of CPM. Culturing of pus yielded a slow-growing, dematiaceous fungus which was identified as Fonsecaea pedrosoi. Combined therapy of amphotericin B and 5-fluorocytosine had little or no effect as the patient continued to have spiking fever and his condition remained more or less unchanged. Medical care of the patient was unfortunately discontinued as he was discharged, with a rather poor prognosis, at the insistence of his family and against medical advice. Prior to this case, work had been done on identifying the agents responsible for two previously diagnosed cases of CPM in Saudi patients with fatal outcome. The dematiaceous fungi that were isolated remained sterile for quite a time before we succeeded in inducing sporulation. Both these isolates were also identified as being Fonsecaea pedrosoi.

Cranial and intracranial aspergillosis of sino-nasal origin. Report of nine cases.

This paper is an attempt at defining the most efficacious surgical and antifungal therapy for invasive cranial and intracranial aspergillosis, and is based on experience with nine non-immunocompromised patients treated and followed-up by the authors between 1983 and 1994; as well as on the summary of previously reported cases and advances in therapy of this condition. Depending on the degree of aspergillar involvement of the cranial base and intracranial structures, a classification, with implications for treatment and prognosis, is also proposed. Two patients had extracranial skull base erosion; whereas relentlessly progressive granulomas, mimicking malignancy, invaded the skull base and intracranial contents in seven cases. Of these seven patients with cranial and intracranial invasion, two died of acute intracranial haemorrhage due to fungal invasion of cerebral blood vessels. In two patients, complete surgical eradication of the disease proved impossible due to cavernous sinus involvement, while residual aspergillomas are still present in orbit and paranasal sinuses (PNS) in a further two patients in spite of multiple surgical procedures and prolonged antifungal chemotherapy (AFC). What appears to be a cure has been effected in one patient only. Multiple therapeutic strategies were used. Biopsy plus systemic AFC was ineffective, surgical drainage and debridement plus systemic AFC resulted in long-term survivals but no cure. Radical surgery in conjunction with systemic and local (intracavitary) AFC should be considered to improve an otherwise poor prognosis.

Prevalence of Candida dubliniensis among germ tube-positive yeasts recovered from the respiratory specimens in HIV-negative patients.

The present investigation was conducted to identify Candida dubliniensis, from respiratory specimens, recovered from HIV-negative patients. Over a 7-month period, 75 germ tube and chlamydospore-positive yeasts were screened for C. dubliniensis, using a variety of phenotypic characteristics. Their identification was based on sugar assimilation reactions using API 20 C Aux. A total of seven (9%) isolates recovered from sputum, bronchial lavage and nasopharyngeal aspirate were identified as C. dubliniensis. All the isolates were susceptible to amphotericin B. One isolate each showed resistance to fluconazole and ketoconazole, and two were resistant to itraconazole. A significantly high percentage (43%) of C. dubliniensis showed resistance to flucytosine.