Screening Candida auris through a multiplex stepwise PCR algorithm directly from clinical samples of patients suspected of otomycosis in south of Iran; Detection of five cases.

BACKGROUND: Otomycosis is an infection of the external auditory canal caused by molds and yeasts with descending frequency. Laboratory diagnosis is usually confirmed by microscopy and culture. However, they are not specific enough to reliably differentiate the causative agents, especially for rare pathogens such as Candida auris. The purpose of the current study was to the molecular screening of C. auris species from direct clinical samples of patients with suspected otomycosis in Southern of Iran. MATERIALS AND METHODS: A total of 221 ear aspirates collected from 221 patients with suspected otomycosis over a four-year period. All the ear aspirations were examined with pan-fungal primers, then those with a positive result was included in two separate reaction mixtures simultaneously to identify the most clinically relevant Aspergillus and Candida species. The validity of positive samples for C. auris was assessed by sequencing. RESULTS: Of the 189 pan-fungal positive PCRs, 78 and 39 specimens contained Aspergillus spp. and Candida spp., respectively. Furthermore, 65 specimens showed simultaneous positive bands in both Candida and Aspergillus species-specific multiplex PCR including five samples/patients with positive result for C. auris (5/189; 2.6%). Four out of five cases with C. auris species-specific PCR were reconfirmed by sequencing, while none were positive for C. auris in culture. CONCLUSION: Unfortunately, due to high treatment failure rates of antifungal classes against C. auris species, rapid and accurate identification of patients colonised with C. auris is critical to overcome the challenge of preventing transmission. This PCR assay can be successfully applied for rapid and accurate detection of C. auris directly in patient samples and is able to differentiate C. auris from closely related Candida species.

Pathogenic Aspergillus Strains Identification and Antifungal Susceptibility Analysis of 452 Cases with Otomycosis in Jingzhou, China.

OBJECTIVE: To study the distribution of pathogenic Aspergillus strains of otomycosis in central China and the identification of their antifungal sensitivity. METHODS: We collected external ear canal secretions clinically diagnosed as otomycosis from April 2020 to January 2023 from the Department of Otolaryngology-Head and Neck Surgery in central China. The pathogenic Aspergillus strains were identified through morphological examination and sequencing. The antifungal sensitivity was performed using the broth microdilution method described in the Clinical Laboratory Standard Institute document M38-A3. RESULTS: In the 452 clinical strains isolated from the external ear canal, 284 were identified as Aspergillus terreus (62.83%), 92 as Aspergillus flavus (20.35%), 55 as Aspergillus niger (12.17%). In antifungal susceptibility tests the MIC of Aspergillus strains to bifonazole and clotrimazole was high,all the MIC90 is > 16 ug/mL. However, most Aspergillus isolates show moderate greatly against terbinafine, itraconazole and voriconazole. CONCLUSION: A. terreus is the most common pathogenic Aspergillus strain in otomycosis in central China. The selected topical antifungal drugs were bifonazole and clotrimazole; the drug resistance rate was approximately 30%. If the infection is persistent and requires systemic treatment, terbinafine and itraconazole can be used. The resistance of Aspergillus in otomycosis to voriconazole should be screened to avoid the systemic spread of infection in immunocompromised people and poor compliance with treatment. However, the pan-azole-resistant strain of Aspergillus should be monitored, particularly in high-risk patients with otomycosis.

Multicentric Case Series and Literature Review of Coccidioidal Otomastoiditis.

Coccidioidomycosis involving the ear, mastoid bone, or both is uncommon. We describe 5 new cases from the United States and review 4 cases reported in the literature of otomycosis and mastoiditis caused by Coccidioides. Of the 9 cases, 8 were linked to residence in or travel to California. Two patients had poorly controlled diabetes mellitus, 7 had otomastoiditis, 1 had otitis externa without mastoid involvement, and 1 had mastoiditis without otic involvement. Four patients had concurrent or prior pulmonary coccidioidomycosis. Ipsilateral facial nerve palsies developed in 2 patients. All patients received antifungal treatment for varying durations, and 8 of the 9 patients underwent surgical debridement. Clinicians should consider coccidioidomycosis as a differential diagnosis for otomastoiditis in patients with geographic risks.

Aspergillus welwitschiae; an otomycosis predominant agent, new epidemiological and antifungal susceptibility data from Iran.

BACKGROUND: Black aspergilli (section Nigri) are predominate etiologic agents of otomycosis, however, there is controversy in the exact differentiation of species. For several decades Aspergillus niger is considered the main otomycosis etiologic agent. Recently calmodulin gene has been accepted as a more suitable gene for the accurate assignment of Aspergillus species. Therefore, it is found that A. welwitschiae and A. tubingensis are the main otomycosis agents based on calmodulin gene sequencing. AIMS: The objective of the study was to isolate and identify black aspergilli from otomycosis using the calmodulin gene and their susceptibility was evaluated against several antifungals. METHODS: 134 clinically confirmed patients with otomycosis were sampled and specimens were cultured on Sabouraud dextrose agar (SDA) at ambient temperature. Black aspergilli were screened based on colony morphology on SDA and microscopy features and then subjected to sequencing using calmodulin primers. Moreover, antifungal susceptibility for isolates was applied based on CLSI M38 3rd edition. RESULTS: 132 (98.5%) of patients had positive cultures for different species of molds or yeasts. Most of the patients (30.3%) ranged from 31 to 40 years, and 56.1% of them were female. Aspergillus section Nigri was the most prevalent fungal pathogen and of 86 isolates, 60.5% isolates were identified as A. welwitschiae, A. tubingensis, 31 (36.0%), A. niger (sensu stricto), 2 (2.3%), and A. neoniger 1 (1.2%). According to the maximum likelihood method, all isolates of A. tubingensis and one isolate of A. neoniger were included in the A. tubingensis clade. On the other hand, the clade of A. niger/A. welwitschiae contains, all isolates of A. welwitschiae, two A. niger (sensu stricto) isolates, and 36 isolates from other countries. Aspergillus welwitschiae was more sensitive to luliconazole, voriconazole, and amphotericin B compared to A. tubingensis. 78.8% of A. welwitschiae strains were classified as non-wild type to nystatin compared to 35.5% of A. tubingensis. Moreover, 3.2% of A. tubingensis strains were non-wild type against amphotericin B. The isolates of A. tubingensis were more sensitive to itraconazole than A. welwitschiae. CONCLUSIONS: It is concluded that in contrast, to the previous study A. welwitschiae from section Nigri is the most causative agent of otomycosis followed by A. tubingensis. In addition, the isolates of A. welwitschiae were more sensitive to luliconazole, voriconazole, and amphotericin B compared to A. tubingensis. Whereas, the isolates of A. tubingensis were more sensitive to itraconazole than A. welwitschiae. On the other hand, 78.8% and 35.5% of A. welwitschiae and A. tubingensis strains were classified as a non-wild type against nystatin. Also, 3.2% of A. tubingensis strains were non-wild type against amphotericin B. All A. welwitschiae were included in the A. niger/A. welwitschiae clade, associated with different clinical and environmental species from different countries.

Otomycosis: The foremost aetiological agent causing otitis externa and the antifungal susceptibility pattern in North-Western Iran.

BACKGROUND: Otomycosis is considered a recurring fungal ear infection. The external auditory canal provides an appropriate and optimal situation for fungal growth. OBJECTIVES: The study aimed to identify the causative agents of otomycosis and determine corresponding antifungal drug susceptibility patterns in north-western Iran. METHODS: From October 2020 until November 2021, 200 patients attended an otolaryngology referral centre with otitis externa, and their ear discharge and debris were examined and cultured. The identification of the fungal agents was implemented by polymerase chain reaction-restriction fragment length polymorphism and sequencing. In vitro antifungal susceptibility testing of the isolates was conducted in accordance with the CLSI broth microdilution protocols. RESULTS: The prevalence of otomycosis was measured 50.5% (n = 101/200). The majority of patients were in their forties (n = 35, 34.6%) and female (n = 57, 56.4%), and the most prevalent symptom was otalgia (56.4%). The most underlying factor was remarked manipulation employing a cotton swab (65.3%). Regarding fungus, Aspergillus section Nigri (58.57%) was the foremost isolate, followed by Aspergillus section Flavi (19.23%) and Candida parapsilosis (14.96%). The predominance of Aspergillus isolates had minimal in vitro sensitivity to tioconazole and nystatin. Candida species represented higher geometric mean minimum inhibitory concentrations (MIC) against nystatin. The MIC of three Aspergillus species isolates shown above the epidemiologic cut-off values (ECV) against itraconazole. CONCLUSIONS: Otomycosis incidence surpassed in comparison with the previous study as the most common cause of otitis externa. The MIC distribution of Aspergillus species isolates against triazole antifungals is close to the defined ECVs and likely outrun it over time.

In Vitro Combination of Terbinafine with Ketoconazole Against Aspergillus Species with Terbinafine High MIC Values Isolated From Otomycosis.

Otomycosis is a common mycotic infection of the external auditory canal, and Aspergillus species are one of the most frequent causative agents worldwide. The limited antifungal arsenal, the high toxicity and side effects of antifungal agents, and the growing resistance to the currently available antifungals underscore the need for new therapeutic strategies. The present study aimed to evaluate the combined in vitro efficacy of terbinafine and ketoconazole against Aspergillus species with terbinafine high MIC values isolated from patients with otomycosis.84 Aspergillus species with high MIC values to terbinafine (≥ 4 µg/ml), consisting of A. flavus, A. tubingensis, A. niger, and A. terreus, were included in this study. The checkerboard microdilution method evaluated the in vitro interactions using the CLSI reference technique. Synergistic effects were observed for 66.67% (56/84) of all isolates (FICI ranging from 0.19 to 0.5). However, the interactions of terbinafine and ketoconazole exhibited indifference in 33.33% (28/84) of the isolates, and no antagonism was observed for any combination. The interaction of terbinafine and ketoconazole showed synergistic activity against Aspergillus species with high MIC values, suggesting that this is an alternative and promising approach for treating otomycosis.

Identification of Microbial Community in Otomycosis by Metagenomic Next Generation Sequencing (mNGS): Potential Implication of Treatment with Terbinafine.

The present study was designed to identify the microbial community as well as to analyze its diversity by means of metagenomic Next Generation Sequencing (mNGS) in 17 patients with otomycosis treated with terbinafine in the Department of Otolaryngology of Shandong Provincial Hospital from June 2021 to June 2022, so as to evaluate the relationship between microbial community and terbinafine resistance. Those 17 patients were divided into two groups, i.e., Terbinafine Effective Group (TEG, n = 14 cases) and Terbinafine Resistance Group (TRG, n = 3 cases) according to the therapy effect, whose microbial community of secretion of external auditory canal was identified using mNGS. We found that the sequence of bacteria was significantly more than that of fungi and, whereas, the difference between the two groups of bacteria was not significant. There were significant differences in fungal community between the two groups. Aspergillus was the main pathogenic fungus of TEG patients while Malassezia was a dominant fungus in TRG patients. In conclusion, the results from this work indicate that Aspergillus terreusis is the main pathogenic fungus in this cohort of otomycosis patients and MNGS sequencing can offer comprehensive information about the microbial community of otomycosis. The fungus community dominated by Malassezia is more likely to be resistant to terbinafine, which provides certain guidance for clinical treatment of otomycosis with terbinafine.

Clinical and microbiological profile of otomycosis in Lagos, Nigeria.

Introduction: Otomycosis is a global disease, common in the world's tropical and subtropical regions. The diagnosis is clinical, but mycological examination is required for its confirmation. There is a paucity of published data on otomycosis particularly the aetiologic agents in Nigeria. This study aims to fill in this gap by assessing the clinical presentations, risk factors and aetiologic agents of otomycosis in our setting. Methods: This was a prospective study of 126 clinically diagnosed patients and 30 controls. Mycological analysis of debris and swab samples from their external auditory canal was carried out. Results: One hundred and twenty-six patients were recruited, with 162 ear samples collected. There was mycological confirmation of otomycosis in 100 (79.4%) patients (subjects) and 127 (78.4%) specimens. The subjects' age range was 1-80 years, 30.89 ± 21.15 mean age, and 29-year median age. The peak prevalent age of 1-10 years was statistically significant, P = 0.022. The common symptoms in the subjects were itching 86 (86%), ear blockage 84 (84%) and otalgia 73 (73%). Regular ear cleaning 67 (67.0%) was the most common risk factor. Noted aetiologic agents were Aspergillus species 81 (63.8%), Candida species 42 (33.1%) and Yeast 4 (3.1%). Aspergillus flavus (40/127; 31.5%) was the most common fungus isolated. Unilateral otomycosis 73 (73%) was more common than bilateral otomycosis 27 (27%). Conclusion: Otomycosis is common in all ages, and is a commonly unilateral disease. Regular ear cleaning is the most common risk factor. A. flavus was the most common aetiologic agent in this study.

THE MICROBIOLOGICAL STRUCTURE OF OTOMYCOSIS: SENSITIVITY PROFILE OF AGENTS TO ANTIFUNGAL DRUGS.

OBJECTIVE: Aim: To study the species composition of microorganisms isolated from patients with otomycosis, and to control the sensitivity of isolated microorganisms to the most commonly used antifungal drugs. PATIENTS AND METHODS: Materials and methods: The main group of study was 132 patients with a preliminary diagnosis of Otomycosis was carried out in the period 2020-2022.To study the sensitivity of isolated microorganisms to antifungal drugs, the Himedia paper disk method (India) was used. RESULTS: Results: Analysis of studies showed that among 132 patients, fungal infection was found in 101 patients (76%), the cultural method - in 31 patients (23.5%); of them women - 56 (42.4%), men - 60 (45.5%) aged 16 to 76; children - 16 (12.1%) aged 6 to 12 years. However, among all patients (n = 132) with otomycosis, fungal lesions of the outer ear prevail, which were detected in 85 (64.4%) patients, that is, fungal otitis was detected in 47 (35.6%). CONCLUSION: Conclusions: The general structure of the species spectrum of etiologically significant pathogens of otomycosis: Candida spp. (78.0%) of the total spectrum of isolates. The sensitivity of isolated micromycetes to antifungal drugs varied in different fungal species and in different antifungal drugs.

[Efficacy and safety of topical combination therapy in patients with acute otitis externa].

AIM: To study the structure of the microbial landscape in patients with acute otitis externa, as well as to evaluate the efficacy and safety of the combined drug chloramphenicol/clotrimazole/beclomethasone/lidocaine (Candibiotic) as an empirical therapy of this disease. MATERIALS AND METHODS: In this retrospective study of real clinical practice, outpatient records of 963 patients who applied to the KDO of the Sverzhevsky Research Clinical Institute of Otorhinolaryngology with symptoms of otitis externa in the period from 2017 to 2022 were selected. Additional analysis was carried out on the clinical records of patients who received the combined drug Candibiotic. The endpoints of this analysis included data on the clinical and microbiological efficacy of therapy, as well as safety information. RESULTS: According to microbiological testing, 60.6% of microorganisms belonged to bacterial flora, 26% were bacterial-fungal associations, 11.6% were monofungal flora, in 1.8% of cases there was no growth of microorganisms. The most frequently isolated microorganisms were: Pseudomonas spp (n=291; 29.16%), Staphylococcus spp. (n=214; 21.4%), Candida spp. (n=194; 19.4%), Aspergillus spp. (n=133; 13.3%). Most of the patients (71.0%) received Candibiotic. In 69.7% of patients, the resolution of the clinical symptoms of otitis externa occurred within 7 days of therapy with Candibiotic. Complete eradication of microorganisms occurred in 87% of cases. Adverse events were recorded only in 3 (0.04%) cases. CONCLUSION: The study demonstrated an extremely high level of clinical efficacy and safety of therapy in patients with acute external infectious otitis who received the Candibiotic, which can be used as an initial empirical therapy in patients with otitis externa.

UK standards for microbiology investigations of ear infection (SMI B1) are inadequate for the recovery of fungal pathogens and laboratory diagnosis of otomycosis: A real-life prospective evaluation.

BACKGROUND: We evaluated the recovery of fungal pathogens from clinical external ear samples from patients with otitis externa (OE) using the UK national Standard Microbiology Investigations of ear infection (SMI B1). METHOD: The UK SMI B1 protocol including a single Sabouraud dextrose agar with chloramphenicol (SABC) incubated at 37°C for 48 hours was compared with a standard fungal-specific culture method using two SABC agar plates incubated at 28 and 37°C for 2 weeks with an extra Candida chromogenic agar incubated at 37°C for 5 days. This real-life evaluation was undertaken on ear samples from patients with OE from January 2020 to December 2020. RESULTS: Altogether, 304 individual patient ear swabs were prospectively examined. The positivity rate of UK standard was 14% (42/304) versus 26% (79/304) for the fungal-specific protocol (p < .05). The standard protocol identified seven compared with 17 species using the fungal-specific protocol. A total of 93 fungal isolates were recovered; nine different yeasts and eight filamentous fungal species. Candida parapsilosis (38/304; 13%), C. albicans (10/304; 3%) and C. orthopsilosis (6/304; 2%) were common yeast species. Aspergillus niger complex (16/304; 5%) was the most common mould, followed by A. fumigatus complex (3/304; 1%). Many less common and emerging yeasts and moulds were only isolated from samples cultured using a fungal-specific protocol. CONCLUSION: Our results suggest that the UK SMI B1 media and procedures are inadequate to detect all fungal agents causing otomycosis. Fungal-specific culture protocols increase the recovery rate and diversity of fungal pathogens isolated from external ear samples.

Otomycosis in the South of Iran with a High Prevalence of Tympanic Membrane Perforation: A Hospital-Based Study.

INTRODUCTION: Otomycosis is a superficial infection of the external ear caused by fungal pathogens. The genera Aspergillus and Candida are considered the main fungal causative agents, with the predominance of Aspergillus section Nigri. The present study aimed to evaluate the clinical symptoms of patients with otomycosis and predisposing factors and to identify fungal etiological agents using molecular approaches. We also present an overview of published papers on tympanic membrane perforation (TMP) secondary to otomycosis. MATERIALS AND METHODS: An otorhinolaryngologist collected specimens from external ear canals of patients with suspected otomycosis based on the patient's history and clinical examinations. The specimens were collected using sterile swabs. Fungal isolates were confirmed in clinical specimens by direct microscopy and culture methods. Fungal isolates were identified based on molecular approaches. RESULTS: In total, specimens from 211 patients with suspected otomycosis were examined. The presence of fungi was confirmed in about 51% of patients based on fungal elements in direct microscopy and culture-positive fungi. Aspergillus tubingensis was the most commonly isolated species (52.77%), followed by Aspergillus niger (25.92%). Otomycosis due to infection with Candida species was observed in 16% of cases. Of note, in 36.11% of cases, otomycosis was associated with TMP. CONCLUSION: A mycological examination is indispensable for a correct diagnosis in patients with otitis extern. TMP should be considered in patients with otomycosis, as it appears to be relatively common in this population.

A Chronic Autochthonous Fifth Clade Case of Candida auris Otomycosis in Iran.

Candida auris, a multidrug-resistant nosocomial pathogen, has emerged globally with high morbidity and mortality among immunocompromised individuals and COVID19 hospitalized patients. Five major clades of C. auris have been previously described. The fifth clade is exclusively found in Iran where C. auris isolates are genetically distinct from other clades by > 200,000 single-nucleotide polymorphisms. The origin of C. auris remains unclear, and limited clinical data are available at present regarding clade V infection or colonization. Herein, another case of otomycosis in Iran caused by an isolate of C. auris belonging to the fifth clade is reported. Genotyping revealed that the obtained C. auris isolate from Isfahan clustered with earlier clade V isolates from Babol, cities around 600 km separated, which indicates that C. auris clade V is established in Iran. C. auris is thought to exist more commonly in Iran, given that limited diagnostic capacity in the country has probably curbed the identification of more C. auris cases. Therefore, surveillance of the environment, patients and healthcare facilities in different geographical regions in Iran is urgently required.

Different repartition of the cryptic species of black aspergilli according to the anatomical sites in human infections, in a French University hospital.

Black aspergilli of the section Nigri are rarely differentiated at the species level when originating from human specimens. We wondered whether some cryptic species could be more frequently observed in some clinical entities. We analyzed the 198 black isolates consecutively collected from the external ear canal (EEC; n = 66), respiratory specimens (n = 99), and environment (n = 33). DNA was extracted and species identification was performed upon the partial calmodulin gene. We identified by decreasing frequency: Aspergillus welwitschiae (35.3%), Aspergillus tubingensis (34.3%), Aspergillus niger (17.2%), Aspergillus luchuensis (4%), Aspergillus aff. welwitschiae (3%), Aspergillus neoniger (2%), Aspergillus piperis (1.5%), Aspergillus japonicus (1.0%), Aspergillus vadensis (0.5%), and two Aspergillus tubingensis clade (1%). The distribution of the three main cryptic species was different between EEC and respiratory samples (P < 0.001) but not different between respiratory and environment samples (P = 0.264). Aspergillus welwitschiae was more often associated with EEC (54.5%), whereas A. tubingensis and A. niger were predominant in respiratory samples (39.4 and 26.3%, respectively). Among the 99 respiratory isolates, only 10 were deemed responsible for probable invasive aspergillosis, of which six were mixed with other pathogenic moulds. This study shows the interest to pursue the identification of clinical isolates in the Aspergillus section Nigri to unravel some specific associations with clinical entities. The association of A. welwitschiae with otomycosis suggests a better fitness to infect/colonize the ear canal. Also, members of the Aspergillus section Nigri alone are rarely responsible for invasive aspergillosis. LAY SUMMARY: We analyzed 198 black aspergilli isolates collected from different samples type to determine their species identification. We observe a different distribution of species between ear canal and respiratory samples (P < 0.001), suggesting a better fitness of A. welwitschiae to infect the ear canal.

Efficacy of topical isoconazole nitrate in the treatment of otomycosis.

PURPOSE: Various agents with various antifungal properties are widely used for otomycosis eradication. However, there is still no consensus on the most effective agent. Therefore, the present study aims to investigate the efficacy of topical 1% isoconazole nitrate cream in the treatment of otomycosis. METHODS: This prospective study included 43 patients who were applied to our outpatient clinic with complaints of ear pain, itching, aural fullness, and hypoacusis, and were diagnosed with unilateral otomycosis. After aspiration and cleaning, the external ear canal was filled with 1% isoconazole nitrate cream using an iv cannula and insulin syringe. Control examinations were performed on the 5th, 10th, 15th, and 20th days. In the follow-up examinations, patients were asked about how many days after the cream administration the pain and itching completely relief and the answers were recorded. RESULTS: In the first control examination of 23 (92%) of 25 patients with pain, it was observed that the pain and otoendoscopic examination findings completely recovered. In the second control, it was found that both pain and otoendoscopic examination findings completely recovered in the remaining 2 patients (25 patients, 100%). 35 patients complained of itching and it was observed that itching and otoendoscopic examination findings completely recovered in 26 patients (75%) in the first control, 5 more patients (31 patients, 88.6%) in the second control, and 2 more patients (33 patients, 94.3%) in the third control examination. CONCLUSION: Isoconazole nitrate cream appears to be an effective and easily applicable agent for the treatment of otomycosis.

A Case of Topical Ofloxacin-Induced Otomycosis and Literature Review.

The prevalence of fungal otitis externa, or otomycosis, has been increasing in recent decades. Fungi may act as primary pathogens in this condition, or they may occur as secondary infections after prolonged ototopical treatment with antibiotics, which alters the flora of the external auditory canal (EAC) and enables overgrowth of its fungal inhabitants. We report here a case of otomycosis by Candida parapsilosis, Malassezia obtusa, and Malassezia furfur as a secondary infection following prolonged otic ofloxacin treatment. To the best of our knowledge, although isolation of C. parapsilosis and M. furfur from the EAC is not uncommon, the recovery of M. obtusa has not yet been reported. We also conducted a literature review of the searchable data on PubMed concerning the isolation of Malassezia species from the human EAC.

Molecular Identification and Antifungal Susceptibility of Yeasts and Molds Isolated from Patients with Otomycosis.

Fungal otitis externa, an infection of the external auditory canal caused by molds and yeasts, accounts for approximately 10-20% of ear canal infections accompanying high recurrence. The purpose of the current study was to assess the pattern of etiological agents of otomycosis and resistance profile as well as the rate of tympanic membrane perforation. A total of 1040 patients with symptoms of fungal otitis externa, in a period of two years, were investigated. The mycological tests revealed the presence of different fungi in 237 ears (22.8%). Fungal otitis was more related to filamentous fungi of the species Aspergillus flavus (54.43%), A. tubingensis (10.97%), and A. niger (8.86%), followed by yeasts, Candida orthopsilosis (7.59%), C. albicans (6.75%), and C. parapsilosis (5.06%). Tympanic membrane perforation rate was found to be 6.75% and was more common with otomycosis caused by A. flavus, A. tubingensis and C. albicans. In antifungal susceptibility tests, all tested drugs showed generally good activity against most isolates of molds and yeasts, while tolnaftate, clotrimazole, nystatin, and terbinafine had lowest effects. We found that among Aspergillus isolates, one A. niger isolate was resistant to voriconazole, and one A. flavus isolate was resistant to amphotericin B. Furthermore, among Candida species, three isolates of C. orthopsilosis showed high MIC values to fluconazole, two C. albicans isolates were considered fluconazole resistant and one isolate of C. parapsilosis was resistant to caspofungin and 3 isolates were resistant to fluconazole. Regarding the existence of the cases with perforated tympanic membrane and emerging species causing fungal otitis in the current report, the importance of the early physical examination, precise molecular identification, and the antifungal susceptibility evaluation is highlighted.

First molecular report of causative agent of otomycosis due to Aspergillus luchuensis.

Otomycosis is a fungal infection of the external auditory canal caused mainly by the genus Aspergillus. Aspergillus luchuensis, an industrially important fungus, is a member of Aspergillus section Nigri. In this report, we present a case of otomycosis due to Aspergillus luchuensis in a 43-year-old female patient. We performed a partial PCR-sequencing of ß-tubulin and calmodulin genes to identify the isolate to the species level. Further, we determined the in vitro susceptibility of the isolate to nystatin, clotrimazole and itraconazole according to the Clinical & Laboratory Standards Institute (CLSI) M38-A2 protocol. Accordingly, the minimum inhibitory concentrations of clotrimazole, nystatin and itraconazole were 0.25µg/mL, 0.5µg/mL and 1µg/mL, respectively. This is the first report of clinically relevant isolation of Aspergillus luchuensis identified by a molecular technique as a causative agent of otomycosis.

Various topical antifungal agents in otomycosis, which is the best?

OBJECTIVE: To assess the effectiveness of some topical non-specific antifungal agents compared to topical specific antifungal drugs in otomycosis therapy. METHODS: The single-blind comparative prospective study was conducted from January 1, 2018, to January 1, 2019, at the outpatient department of Al Yarmouk Teaching Hospital, Baghdad, Iraq, and comprised patients presenting with signs and symptoms of otomycosis. The clinical diagnosis was made using otomicroscopy and was confirmed by ear swab results. They were classified into 3 equal groups, with group A receiving 1% clotrimazole ear drops, group B 3% salicylic acid drops, and group C 10% povidone iodine drops. Treatment in all the groups lasted three weeks. Data was analysed using SPSS 20. RESULTS: Of the 120 patients, 40(33.3%) were in each of the three groups. Overall, there were 62(51.6%) males and 58(48.4%) females with a mean age of 30.79±7.82 years. The left ear was affected in 70(58.33%) patients, and the right ear in 50(41.66%). The most commonly detected symptom was itching in 102(85%) patients. The type of fungus detected was aspergillus niger in 67(55.84%) patients and candida albicans in 53(44.16%). The overall response to treatment was in 90(74.99%) patients; group A 39(97.5%), group B 29(72.5%), and group C 21(52.5%) (p=0.0001). CONCLUSIONS: Local antifungal agents clotrimazole, 3% salicylic acid and 10% povidone iodine were effective in the treatment of otomycosis with varying degrees of success, with clotrimazole being the most effective.

The myringoplasty of the perforation with otomycosis.

In consideration of the American Journal of Otolaryngology's reviewing and editing my submission, the author(s) undersigned transfers, assigns and otherwise conveys all copyright ownership to Elsevier Inc. in the event that such work is published in the American Journal of Otolaryngology.