Covid-19-associated rhino-orbito-cerebral mucormycosis (CAROM) in Delhi: Demographics and risk factors in a single-centre consecutive cohort of 200 inpatients

BACKGROUND There was a dramatic rise in the incidence of rhino-orbito-cerebral mucormycosis associated with the 2021 Covid-19 wave in India. We aim to document the demographic characteristics and risk factors of a consecutive cohort of inpatients with Covid-19-associated rhino-orbito-cerebral mucormycosis (CAROM) during the surge of April–June 2021. METHODS We included all patients of CAROM treated at our tertiary referral facility from 1 April to 14 June 2021. We prospectively gathered details with regard to Covid-19 illness and treatment, CAROM presentation, comorbid conditions and risk factors. RESULTS Our prospective cohort consisted of 200 consecutive patients, of which 146 (73%) patients tested positive on the Covid-19 RT-PCR test at presentation. CAROM occurred concurrent with the Covid-19 infection in 86%, and delayed CAROM after seeming recovery from Covid-19 was seen in 14%. Covid-19 was classified as mild, moderate and severe in 54%, 33% and 13%. The surge of CAROM followed the population peak of Covid-19 infections by about 3 weeks. Advanced disease at presentation was frequent with ocular involvement in 56.6% (111/196) and central nervous system involvement in 20% (40/199). One or more comorbid conditions were identified in 191/200 (95.5%) patients. The dominant associations were with diabetes (189/200; 94.5%) and uncontrolled hyper-glycaemia (122/133; 91.7%), recent steroid use (114/ 200; 57%), which was often considered as inappropriate in dosage or duration, lymphopenia (142/176; 80.7%), and increased ferritin levels (140/160; 87.5%). No evidence supported the role of previous oxygen therapy or previous nasal swab testing as risk factors for CAROM. CONCLUSION The inpatient volumes of CAROM were noted to parallel the Covid-19 incidence curve by about 3 weeks. Covid-19 infection may directly predispose to CAROM by way of lymphopenia and increased ferritin levels. Uncontrolled hyperglycaemia is identified as a near-invariable association. Recent steroid use is noted as very frequent and was often received in excess of treatment advisories.

Diagnosis of Invasive Fungal Infections in Children

Invasive fungal infections are important causes of morbidity and mortality particularly in high-risk patients. Recognizing such infectionsis often difficult because of non-specific symptoms and clinical signs. Timely diagnosis is also a challenge due to difficulty in obtainingadequate volume of samples, need for anaesthesia to perform certain diagnostic procedures, and insufficient data and experiencerelated to fungal biomarkers and molecular detection tests. This results in widespread use of empiric broad spectrum antifungal agentswith the consequent emergence of drug-resistant strains. This review focusses on the definition, clinical and microbial profile anddiagnostic modalities for invasive fungal infections.

Galactomannan Antigen Test for Early Diagnosis of Invasive Aspergillus Infection in Pediatric Febrile Neutropenia

Invasive aspergillosis is a major concern in neutropenic patients.We studied the utility of Galactomannan antigen detection test inserum using ELISA technique for early detection of invasiveaspergillosis. Diagnostic accuracy of Galactomannan index (GMI)test was maximum at a cut-off of > 1.5 with a negative predictivevalue of more than 95%

Central venous catheter related bloodstream infections in medical intensive care unit patients in a tertiary referral centre.

Aims. To determine the incidence of central line associated bloodstream infections (CLABSIs) in the medical intensive care unit (ICU) and ward setting at All India Institute of Medical Sciences (AIIMS), New Delhi. Settings and Design. The study was conducted in the medical ICU, a 9-bedded ICU at the AIIMS, a tertiary care teaching hospital. The study design was a prospective observational study. Methods. One hundred patients admitted to medical ICU and the ward at AIIMS with an indwelling, non-tunnelled central venous catheter (CVC) in place at admission and those with a hospital stay with indwelling CVC for more than 48 hours were monitored. These patients were followed daily for the development of new onset sepsis 48 hours after insertion of CVC, in which case three sets of blood samples for culture were drawn over a span of 24 hours. Statistical Methods. Incidence of CLABSIs was measured per 1000 central line days. Results. One hundred patients hospitalised for an aggregate 1119 days acquired 29 hospital-acquired infections (HAIs), a rate of 38.8% or 31.2 HAIs per 1000 hospital days. The incidence of bloodstream infections (BSIs) in this group was 6.8%. No case of laboratory confirmed CLABSIs could be demonstrated. Incidence of clinical sepsis was 27.6% or 8.2 per 1000 CVC days. There were 9 cases out of the 29 patients (39.7%) who had evidence of HAIs with no apparent focus of infection. Only one of these cases had evidence of BSI with isolation of Staphylococcus aureus in both CVC tip culture and the simultaneous blood culture; however the antibiograms were different. Conclusions. The low rate of BSIs in the present study and the absence of occurrence of a laboratory confirmed CLABSI should be interpreted in the light of the small sample size of the study and the multitude of antibiotics received before the development of HAI.

Evaluation of conventional & serological methods for rapid diagnosis of cryptococcosis.

BACKGROUND & OBJECTIVE: Cryptococcosis is a chronic infective condition affecting the central nervous system. Unless diagnosed early and specific treatment instituted it can be fatal. There is an urgent need for a rapid and specific diagnostic tool for better management of the patients. Conventional methods such as culture and India ink are specific but cumbersome and time consuming. Serological methods of detection are rapid but have problems of false positivity and cross-reactivity with other micro-organisms. We carried out this study to compare and evaluate the conventional methods with serological methods of detection of cryptococcal meningitis. METHODS: A comparative evaluation of conventional methods (India ink and culture) with LAT (latex agglutination test) and EIA (enzyme immunoassay) was done in 127 CSF samples using culture and EIA as reference separately. RESULTS: India ink was positive for Cryptococcus in 72.4 per cent of the samples; 56 per cent were culture positive; LAT positive were 85 per cent and 79.5 per cent were positive by EIA. When culture was positive, all other tests were in agreement to it. However, when culture was negative there was significant difference between the pair of discordance of various diagnostic tests. Culture was 83.46 per cent in agreement to India ink, 76.3 per cent to EIA and 70.8 per cent to LAT. EIA was 92.9 per cent in agreement to India ink and LAT; 6.3 per cent showed false positive by LAT. INTERPRETATION & CONCLUSION: EIA is valuable in establishing diagnosis when culture is negative for cryptococcosis. EIA is more specific and has potential advantages over LAT as it gives clear discrimination of positive from negative results. Thus, EIA may be used as a simple, rapid, and reliable serological test for early detection of cryptococcal antigen in clinical samples like CSF in routine laboratories.

Etiology and outcome of oral mucosal lesions in children on chemotherapy for acute lymphoblastic leukemia.

Microbiological cultures were taken from oral cavity and blood in 100 mucositis episodes in 70 children with acute lymphoblastic leukemia (ALL). Oral mucositis was commonest in neutropenic children during induction chemotherapy. Fungal organisms (n=39) were commonest isolate from mucosa followed by bacteria (n=28). Isolation of organism from oral cavity had no association with those isolated from blood. Herpes serology was positive in 16% episodes compared to 2% of controls. Obtaining cultures from oral lesions is useful in appropriate management of lesions and thereby possibly preventing systemic spread.

Differences in the cell wall architecture of melanin lacking and melanin producing Cryptococcus neoformans clinical isolates from India: an electron microscopic study

Cryptococcus neoformans is an important opportunistic fungal pathogen that causes life-threatening infection of the central nervous system. A major virulence factor for C. neoformans is the production of melanin in the cell wall. Using transmission electron microscopy, we studied the cell walls of three pairs of isolates obtained from patients with dual cryptococcal infections, where a melanotic and an albino strain were isolated from the CSF of each patient. Transmission Electron Microscopy revealed that the albino strains lacked a melanin layer whereas a melanin layer was associated with the cell wall of the melanotic strains, comprising approximately 75 percent of the cell wall area. The cell wall size of the melanin producing cells was approximately double the size the albino isolates' cell walls (p value <= 0.003). In this study TEM revealed that the differences in the ultrastructure of the melanin lacking and melanin producing isolates were associated to the cell wall and the melanin layer.

Cryptococcus neoformans é um importante fungo oportunista patogênico que causa infecção no sistema nervoso central, e que pode levar o paciente à morte. Um dos principais fatores de virulência do C. neoformans é a produção de melanina na parede celular. Utilizando microscopia eletrônica de transmissão, nós estudamos as paredes celulares de três pares de isolados obtidos de pacientes com dupla infecção pelo fungo, onde um isolado melanizado e um albino foram isolados do líquor de cada paciente. A microscopia eletrônica de transmissão revelou que as cepas albinas não apresentavam a camada de melanina enquanto que uma camada de melanina estava associada com a parede celular de cepas melanóticas, constituindo aproximadamente 75 por cento da área da parede celular. O tamanho da parede celular das células produtoras de melanina foi aproximadamente o dobro do tamanho da parede celular dos isolados albinos (p < 0,003). Neste estudo, a microscopia eletrônica de transmissão revelou que as diferenças na estrutura dos isolados albinos sem melanina e dos isolados produtores de melanina estava associada à parede celular e a camada de melanina.

Prevalence & susceptibility to fluconazole of Candida species causing vulvovaginitis.

BACKGROUND & OBJECTIVE: Vulvovaginal candidiasis is an important cause of morbidity in women of reproductive age. This study was carried out to determine the species prevalence and susceptibility pattern to fluconazole of yeasts isolated from the vagina of symptomatic women. METHODS: This prospective study was conducted in a rural primary health care center of north India from May 2003 to April 2004 and included 601 married, sexually active women (18-49 yr) with the self reported symptoms of vaginal discharge and/or genital itching and/or genital burning. Specific aetiology of the genitourinary symptoms including candidal infection were determined. Specimens from the lateral wall of vagina were subjected to direct wet mount microscopy and fungal culture on Sabouraud's dextrose agar. Susceptibility testing to fluconazole was carried out using broth microdilution method. RESULTS: Yeasts were isolated in 111 (18.5%) women and these consisted of Candida glabrata (56, 50.4%), C. albicans (39, 35.1%), C. tropicalis (12, 10.8%), C. krusei (3, 2.7%) and C. parapsilosis (1, 0.9%). Susceptibility testing carried out on 30 representative isolates (15 C. glabrata, 10 C. albicans, 4 C. tropicalis and 1 C. parapsilosis) revealed that 21 isolates (70%) were susceptible (MIC, < or = 8 microg/ml) to fluconazole while 9 (30%) were susceptible-dose dependent (S-DD, MIC 16-32 microg/ml). INTERPRETATION & CONCLUSION: Our findings suggest a low prevalence of fluconazole resistance in vaginal candida isolates in our population. However, a high prevalence of non-albicans candida species and increased dose-dependent resistance in these isolates necessitates vigilance since this may warrant a change in the optimal therapy of non-albicans candida vaginitis.

Prevalence of Aspergillus species in clinical samples isolated in an Indian tertiary care hospital.

CONTEXT (BACKGROUND): In recent times, it has become important to determine the prevalence of different Aspergillus species in clinical samples in view of difference in antifungal susceptibility noted in some species. AIMS: To determine the species prevalence of Aspergillus isolates in various clinical samples received in the Mycology Laboratory at our institute. METHOD: Over a period of 4-years, a total of 18,731 samples were processed, and species identification carried out by standard microbiological methods. RESULTS: Four hundred and fifty six samples (2.43%) were culture positive for Aspergillus species. A.flavus (46.93%) was the most common isolate, followed by A.fumigatus (37.72%) and A.niger (15.35%). It was observed that A.fumigatus was the predominant species isolated from blood and respiratory specimens, A.flavus was predominantly isolated from nasal polyps whereas A.niger predominated in nail specimens. Culture positivity was highest in the age group 12-65 years and in males. Sixty-nine patients (15.13%) were admitted to the intensive care unit. CONCLUSIONS: The study highlights the diverse manifestations caused by Aspergillus species in human beings and also throws light on the different species prevalent locally. The knowledge would prove useful in selecting empirical antifungal therapy and formulating prophylactic and pre-emptive strategies.

Comparison of trypsin treatment method and standard laboratory technique for diagnosis of dermatomycosis.

Dermatomycosis is prevalent worldwide. Discrepancy between microscopic examination and culture findings can create problems in the diagnosis of this common infection. In this study, samples from 60 patients were processed after trypsin treatment and examined by neutral red staining to distinguish viable and non-viable fungal elements. The trypsin treatment method was compared with standard laboratory techniques. A higher number of direct-microscopy-positive, culture-negative samples were obtained without trypsin treatment. Trypsin treatment increased the isolation of fungi from clinical samples, and neutral red staining was able to distinguish viable fungal elements.