Trichosporon asahii as an emerging etiologic agent of disseminated trichosporonosis: A case report and an update.

PURPOSE: To report a fatal case of disseminated trichosporonosis caused by Trichosporon asahii in a patient with acute myeloblastic leukemia (AML) and to present an update on systemic trichosporonosis with special reference to India. METHODS: The diagnosis was based on repeated demonstration of budding yeast cells and arthroconidia by direct microscopic examination of sputum and by isolation of T. asahii in culture of sputum and blood. The update is largely based upon literature search in Medline and Review of Medical and Veterinary Mycology. RESULTS: A 41-year-old male presented with acute myeloblastic leukemia, cough and fever. He had received cytotoxic drug therapy, broad spectrum antibiotics and was neutropenic. Trichosporon asahii was repeatedly demonstrated in his sputum by direct microscopy and culture, and also isolated from blood. It was identified by appropriate morphological and physiological characteristics viz., arthroconidium formation, diazonium blue B reaction, urease activity and assimilation of carbon and nitrogen compounds. The identification was confirmed by PCR amplification and direct DNA sequencing of internally transcribed spacer (ITS) 1 and ITS2 of rDNA. CONCLUSION: With greater awareness of etiologic significance of T.asahii, trichosporonosis is likely to be recognised more frequently than apparent from the available published reports.

Sporotrichosis in India: First case in a Delhi resident and an update.

PURPOSE: To report the first case of sporotrichosis in a Delhi resident without history of travel to any known endemic area, and to present an update of the disease with special reference to India. METHODS: OThe case was tentatively diagnosed by clinical features, and confirmed by culture and histopathologic examination of a biopsy specimen. The update on the disease is based upon literature review (1932-2001). RESULTS: A 40-year-old female hospital employee developed lymphocutaneous lesions, involving her right middle finger, wrist and forearm following accidental pricking with a hypodermic syringe needle. A definitive diagnosis of sporotrichosis was established by culture of S. schenckii, verification of its dimorphic character, morphology in histopathologic sections and a positive pathogenicity test (intratesticular inoculation) in male white mice. The patient was successfully treated with saturated solution of potassium iodide. Of 205 cases compiled from literature, 91 (44%) came from West Bengal, 56 (28%) from Himachal Pradesh and 45 from Assam whereas the remaining 13 (6.3%) occurred sporadically in other states, including Bihar, Punjab and Karnataka. CONCLUSIONS: The available literature does not provide a true index of regional distribution of sporotrichosis in India. More correctly, it seems to reflect the distribution of groups of investigators with a special interest or expertise in sporotrichosis and S. schenckii. Further studies are likely to reveal new endemic areas for sporotrichosis.

Prevalence of pulmonary nocardiosis in a tuberculosis hospital in Amritsar, Punjab.

The prevalence of pulmonary nocardiosis in a tuberculosis and chest diseases hospital in Amritsar is reported. Of 1510 sputum samples cultured from 1016 patients, 67 sputa originating from 16 patients were found to be positive for the Nocardia asteroides species complex. Based upon repeated isolation of N. asteroides from the respiratory tract, its microscopic demonstration in KOH wet mounts or stained smears of sputum and clinical evaluation of patients, 14 cases of pulmonary nocardiosis were diagnosed. This gave a prevalence of 1.4% pulmonary nocardiosis in the tuberculosis hospital. The prevalence of the disease was found to be 1.3% in the males as against 1.5% in the females. Of the various clinical categories of patients investigated, pulmonary tuberculosis with sputum negative for acid-fast bacilli (AFB) yielded the highest prevalence of 3.2%, followed by 1.3%, 1.2%, 1.1% and 0.5% in pneumonia, chronic obstructive pulmonary disease (COPD), bronchiectasis and pulmonary tuberculosis with sputum positive for AFB, respectively. Type IV cutaneous hypersensitivity to nocardin was observed in 19 of 908 (2%) patients tested, whereas only a solitary positive reactor was found among 260 healthy volunteers. Twelve of 19 nocardin positive reactors (63%) had unequivocally proven pulmonary nocardiosis. The nocardin skin test gave false negative results in two nocardiosis patients. More comprehensive investigations are warranted in order to evaluate the nocardin skin test as an additional aid for the diagnosis of nocardiosis. Barring a solitary exception, the nocardiosis patients were successfully treated with sulphadiazine or trimethoprim-sulphamethoxazole (TMP-SMZ) combination. To the best of our knowledge, this is the largest series of pulmonary nocardiosis patients in a prospective study as yet reported from India. The observations underscore the point that nocardiosis warrants greater attention in the differential diagnosis of bronchopulmonary diseases.

Occurrence and significance of Cryptococcus neoformans in vegetables and fruits.

Cryptococcus neoformans was isolated from three of 437 (0.6%) samples of a wide variety of vegetables collected from a number of markets in Delhi. The vegetables yielding C. neoformans were tomato, Lycopersicon esculentum (1/70), 'vegetable sponge', Luffa cylindrica (1/56) and brinjal, Solanum melongena (1/55). Only solitary samples of these three vegetables were found to be positive. In vitro studies at 25 degrees C revealed that a reference C. neoformans isolate readily colonized, as did Candida albicans and Candida viswanathii (controls), sterilized slices of almost all the test vegetables and fruits (cut or uncut surface) which included tomato, 'vegetable sponge', brinjal, potato, carrot, radish, apple, guava, pineapple, pear, papaya, banana and mango. Sterilized juices of the same vegetables and fruits also supported adequate growth of the reference C. neoformans isolate as well as of C. albicans and C. viswanathii. However, the growth of C. neoformans on the afore-mentioned vegetables and fruits was rapidly masked by miscellaneous molds and bacteria if the test samples had not been sterilized prior to inoculation. Cryptococcus neoformans was not found in any of the 275 fruit samples investigated from the same markets. The results indicate that vegetables and fruits are unsuitable as natural habitats for C. neoformans although it may be sporadically isolated from these sources.

Respiratory and systemic mycoses: an overview.

Respiratory and systemic mycoses are globally emerging as a problem of increasing importance in infectious diseases. This is attributed to the growing population of immunocompromised patients due to epidemic outbreak of AIDS or to other factors such as use of immunosuppressive drugs in recipients of organ transplantation. The available evidence has unequivocally established the endemic occurrence of blastomycosis, histoplasmosis and penicilliosis mameffei in India. In fact, pencilliosis marneffei has emerged as a major endemic mycosis of AIDS patients in Southeast Asia. It has manifestations simulating those of histoplasmosis capsulati, and it may spread to other regions with enlarging population of AIDS patients. Comprehensive studies are indicated in order to delineate the endemic areas of the afore-mentioned systemic mycoses. Among the other important systemic mycoses reported from India are aspergillosis, cryptococcosis, candidiasis and zygomycosis. Our current knowledge of the global distribution of systemic mycoses does not depict their true prevalence. It largely reflects the geographic distribution of medical mycologists or other investigators engaged in the study of fungal diseases and their research interests. Invasive aspergillosis has emerged as an important disease in patients with neutropenia and bone narrow transplant recipients, cryptoccosis, penicilliosis marneffei and pneumocystosis in patients with AIDS, fusariosis in patients with leukaemia receiving cytotoxic therapy, zygomycosis in diabetic patients and in patients on defroxamine therapy, and Malasseziafurfur infection in patients on total parenteral nutrition: Opportunistic systemic mycoses due to yeasts and yeast-like fungi have become commoner than those due to filamentous fungi, occupying fourth position in the list of bloodstream pathogens in some centers in USA. Also, their incidence, pattern of clinical presentations and species spectrum have significantly changed, largely due to more frequent and prolonged therapeutic or prophylactic use of antifungal drugs and subsequent development of resistance. Consequently, infections with resistant yeast-like fungi such as C. lusitaniae, C. krusei, C. tropicalis, C. glabrata and Trichosporon ovoides (T. beigelii) have recently been reported with greater frequency. Since respiratory and systemic mycoses have no pathognomonic clinical or radiologic syndrome and mycological diagnostic facilities are restricted to only some of the major metropolitan centres, these diseases may be frequently confused with tuberculosis or other diseases of obscure etiology in India and other developing countries. Greater awareness and a high index of clinical suspicion are important pre-requisites for their diagnosis. Also, active collaboration of internists, pathologists, mycologists and microbiologists is advocated for their expeditous diagnosis and successful management. Further studies should focus on the development of rapid techniques for selective isolation and identification of systemic pathogenic fungi. The problem of antifungal resistance is likely to become more serious in the future as more and more patients with AIDS, bone marrow transplantation and neutropenia will require chemoprophylaxis cover against systemic fungal infections. Thus, it would be of vital importance to intensify search for more potent and less toxic antifungal drugs. It is recognized that an increasing number of people whose life is saved or prolonged due to successful treatment of their underlying diseases fall victim to opportunistic, life threatening systemic mycoses. A great majority of the deaths due to these infections occurs because they remain undiagnosed for want of mycological diagnostic services. In order to cope with the challenge of systemic mycoses, the health authorities of the developing countries are called upon to urgently take necessary measures for establishing a network of diagnostic mycology laboratories.

Farmer's lung disease in north-western India--a preliminary report.

A study of farmer's lung (FL) disease was carried out in 197 subjects engaged in farming and having respiratory complaints of varying duration. It revealed that 13.2% of the subjects had precipitating antibodies against thermophilic actinomycetes, with Faenia rectivirgula (Micropolyspora faeni) alone accounting for 85% of the positive reactions. Precipitating antibodies against Thermoactinomyces vulgaris and T. thalpophilus were observed only in 1.5% and 0.5% of the subjects, respectively. Two subjects concomitantly demonstrated F. rectivirgula and T. vulgaris-specific serum precipitins. Sixty (30%) of the subjects related their respiratory symptoms to exposure to wheat straw/thresher's dust or other vegetable substrata in the working environment. Based upon a suggestive clinical history, roentgenography, pulmonary function studies and demonstration of serum precipitins against F. rectivirgula, FL was diagnosed in 4 subjects whose salient features are presented and discussed. To the best of our knowledge, this is the first authentic report on FL from India. A comprehensive epidemiological survey is indicated to determine the prevalence of FL in different geo-climatic regions of the country.