Cryptococcus laurentii fungaemia in a cervical cancer patient

ABSTRACT Infections caused by emerging Cryptococcus non-neoformans species are being reported with increasingly frequency. Here, we present a case of fungaemia byCryptococcus laurentii in a woman receiving aggressive immunosuppressive therapy for cervical neoplasia. Three venous blood samples were aseptically collected on consecutive days and C. laurentiiwas isolated and identified through phenotypic and molecular methods. After central venous catheter removal and appropriate antifungal therapy, the patient showed significant improvement and blood culture became negative. Thus, patients following immunosuppressive therapies and using invasive medical devices are at risk of C. laurentii blood infections.

Invasive infection due to Saprochaete capitata in a young patient with hematological malignancies

We report a case of invasive infection due to Saprochaete capitata in a patient with hematological malignancies after chemotherapy treatment and empiric antifungal therapy with caspofungin. Although severely immunocompromised the patient survived been treated with amphotericin B lipid complex associated with voriconazole.

Primer caso de fungemia por una levadura relacionada con Candida pseudorugosa / First case of fungemia from a yeast related with Candida pseudorugosa

Se presenta el primer caso de fungemia por una especie de Candida relacionada con Candida pseudorugosa. La identificación de las especies de levaduras es de importancia a nivel epidemiológico y para el tratamiento de los pacientes que cursan una infección por levaduras.

Fungemia in a university hospital: an epidemiological approach / Fungemia em hospital universitário: uma abordagem epidemiológica

INTRODUCTION: Fungemia corresponds to the isolation of fungi in the bloodstream and occurs mostly in immunosuppressed patients. The early diagnosis and treatment of these infections are relevant given the serious threat to the affected patients and possible spread to other organs, often becoming fatal. The growing number of fungemia associated with poor prognosis resulted in this research aiming to diagnose and assess the epidemiological aspects of hematogenous infections by fungi. METHODS: The study included 58 blood samples collected within a 1-year period, from patients at the Hospital das Clinicas, Federal University of Pernambuco, by venipuncture in vacuum tubes. Blood samples were processed for direct examination and culture and identification, conducted by observing the macroscopic and microscopic characteristics, as well as physiological characteristics when necessary. RESULTS: Eight (13.8 percent) episodes of fungemia were identified, accounting for the total sample, and these pathogens were Candida, Histoplasma, Trichosporon, Cryptococcus, and a dematiaceous fungus. C. albicans was the prevalent species, accounting for 37.5 percent of the cases. Most affected patients were adult males. There was no predominance for any activity, and the risk of acquired immunodeficiency syndrome was the underlying pathology most often cited. CONCLUSIONS: The isolation of fungi considered as emergent species, such as C. membranifaciens and dematiaceous species, highlights the importance of epidemiological monitoring of cases of fungemia in immunocompromised patients, as the therapy of choice depends on the knowledge of the aethiological agent.

INTRODUÇÃO: Fungemia corresponde ao isolamento de fungos na corrente sanguínea e ocorre, sobretudo, em pacientes imunossuprimidos. O diagnóstico e tratamento precoce destas infecções são relevantes diante da grave ameaça aos pacientes acometidos e possível disseminação via hematogênica para outros órgãos, tornando-se muitas vezes fatal. O crescente número de casos de fungemia associados ao mau prognóstico resultou na realização desta pesquisa que teve por objetivo diagnosticar e avaliar aspectos epidemiológicos das infecções hematogênicas por fungos. MÉTODOS: O estudo incluiu 58 amostras de sangue coletadas, durante um ano, de pacientes internados no Hospital das Clínicas da Universidade Federal de Pernambuco, através da punção venosa em tubos a vácuo. As amostras de sangue foram processadas para exame direto e cultura e a identificação, conduzida através da observação das características macroscópicas, microscópicas e quando necessárias fisiológicas. RESULTADOS: Oito (13,8 por cento) episódios de fungemia foram identificados, correspondendo ao total das amostras e os agentes etiológicos envolvidos foram Candida, Histoplasma, Trichosporon, Cryptococcus e um fungo demáceo. C. albicans foi a espécie prevalente com 37,5 por cento dos casos. A maior parte dos pacientes acometidos pertencia ao sexo masculino, na idade adulta. Não houve predominância para nenhuma atividade de risco e a síndrome da imunodeficiência adquirida foi a patologia de base mais citada. CONCLUSÕES: O isolamento de fungos considerados emergentes como C. membranifaciens e espécies demáceas ressaltam a importância do acompanhamento epidemiológico dos casos de fungemia em imunocomprometidos, uma vez que a escolha terapêutica depende do conhecimento do agente etiológico.

Standardization of fungal polymerase chain reaction for the early diagnosis of invasive fungal infection.

Background: An early initiation of antifungal therapy in invasive fungal infections (IFIs) is critical in reducing the high mortality rate. Current diagnosis of fungal infection relies on microscopy, culture, antigen, antibody specific tests and histological diagnosis. However, these tests either lack sensitivity or specificity. There is thus the need for a rapid, specific and accurate diagnostic method. Objective: The aim of our study was to establish PCR for the rapid detection of Candida and Aspergillus species in clinical specimens with improved sensitivity and specificity. Materials and Methods: A total of 71 proven cases of IFI (confirmed by culture) were collected. A total of 15 healthy, 15 patients suffering from bacterial sepsis and 15 patients with HIV, HBV viral infections were included as controls. Clinical specimens were subjected to a standardized nested amplification to produce Round I (504 bp) and Round II (150 bp) amplicons. Restriction digestion was performed on these products for further identification. Results: Analytical sensitivity was determined using 10 6 -10 CFU/ml of cell suspension. The lower detection limit of the assay was 10 CFU/ml of blood. This test was 100% sensitive and specific with a positive predictive value of 100% and a negative predictive value of 96.7%. Conclusion: The assay was found to be effective for the rapid detection of Candida and Aspergillus in clinical specimens.

A rare case of Histoplasma fungemia in an AIDS patient.

Disseminated cases of histoplasmosis in acquired immune deficiency syndrome (AIDS) are rarely reported from India. Most of these cases report isolation of this fungus from the bone marrow, lymph node aspirate, spleenic aspirate, and biopsies. We report isolation of Histoplasma capsulatum from the blood of an AIDS patient. A 30-year-old male from Utter Pradesh was admitted with fever, loss of appetite, and nausea since two months. Few intracellular and extracellular budding cells were observed on bone marrow examination on the fifth day of admission. Diagnosis was confirmed by blood cultures taken on the 11th day of admission. Amphotericin B was started, but the patient's condition deteriorated and he died.

Invasive candidiasis in pediatric intensive care units.

Candidemia and disseminated candidiasis are major causes of morbidity and mortality in hospitalized patients especially in the intensive care units (ICU). The incidence of invasive candidasis is on a steady rise because of increasing use of multiple antibiotics and invasive procedures carried out in the ICUs. Worldwide there is a shifting trend from C. albicans towards non albicans species, with an associated increase in mortality and antifungal resistance. In the ICU a predisposed host in one who is on broad spectrum antibiotics, parenteral nutrition, and central venous catheters. There are no pathognomonic signs or symptoms. The clinical clues are: unexplained fever or signs of severe sepsis or septic shock while on antibiotics, multiple, non-tender, nodular erythematous cutaneous lesions. The spectrum of infection with candida species range from superficial candidiasis of the skin and mucosa to more serious life threatening infections. Treatment of candidiasis involves removal of the most likely source of infection and drug therapy to speed up the clearance of infection. Amphotericin B remains the initial drug of first choice in hemodynamically unstable critically ill children in the wake of increasing resistance to azoles. Evaluation of newer antifungal agents and precise role of prophylactic therapy in ICU patients is needed.

Central venous catheter-related bloodstream infection and Cryptococcus neoformans

This is the first case reported of central venous catheter-related fungemia due to C. neoformans. A patient with chronic renal failure developed a fungemia during the treatment of a dialysis-associated bacteremia. Cryptococcus neoformans grew in the catheter tip and blood culture. We addressed questions about this catheter-related fungemia.

Diagnóstico molecular de histoplasmosis humana en muestras de sangre entera / Molecular diagnosis of human histoplasmosis in whole blood samples

Se evaluó el uso de sangre entera para el diagnóstico molecular de histoplasmosis utilizando un método artesanal de extracción de ADN fúngico y una PCR anidada que amplifica una porción del gen HcP100 específica de Histoplasma capsulatum. La sangre entera se trató con liticasa, enzima lisante de Trichoderma harzianum y proteinasa K, seguido de una extracción fenólica. Este tratamiento permitió una lisis completa de las células, mostró buen rendimiento en la obtención de ADN y posibilitó la detección de la banda de 210 pb específica de H. capsulatum en la PCR anidada. El límite de detección fue de 0,25-1 levaduras/ml de sangre. El método se evaluó en 31 muestras de sangre de 19 pacientes con diagnóstico microbiológico de histoplasmosis, en 21 muestras de pacientes con otras micosis o infecciones por micobacterias y en 30 controles sanos. La PCR fue positiva en sangre para 17/19 pacientes con histoplasmosis (14/15 inmunocomprometidos y 3/4 sin inmunocompromiso aparente). Las muestras de sangre de los 30 controles sanos y de 20 pacientes con otras patologías fueron negativas, sólo hubo un falso positivo correspondiente a un paciente con infección por Mycobacterium avium-intracellulare. El método presentó 89% de sensibilidad y 96% de especificidad para el diagnóstico de histoplasmosis en sangre entera.

To assess the value of using whole blood samples for the molecular diagnosis of histoplasmosis, we applied an in-house DNA extraction method and a nested PCR targeting a 210 bp specific segment of the Histoplasma capsulatum HcP100 gene. A whole blood volume of 2.5-3 milliliters was centrifuged and the cellular pellet was treated with Trichoderma harzianum lyticase and proteinase K prior to applying a conventional phenol DNA extraction. This procedure allowed complete cell lysis, high DNA yield and specific amplification. The PCR detection limit was 0.25-1 yeast cells/ml of blood sample. The method was assessed on 31 blood samples from 19 patients with microbiological diagnosis of histoplasmosis, 30 healthy persons and 21 patients with other mycoses or mycobacterial diseases. Positive results were obtained in samples from 17/19 patients with histoplasmosis (14/15 immunocompromised and 3/4 without known immunological disorder). Blood samples from the 30 healthy controls and 20 patients with other conditions proved negative; the only false positive result was obtained from a patient with Mycobacterium avium-intracellulare infection. With 89% sensitivity and 98% specificity, this molecular method for detection of the agent in blood shows promising for the rapid diagnosis of human histoplasmosis.

Catheter-related candidemia caused by Candida lipolytica in a child with tubercular meningitis.

Candida lipolytica is weakly pathogenic yeast, which is rarely isolated from the blood. We recovered this species from repeated blood samples and in the central venous catheter in a debilitated pediatric patient of tubercular meningitis. Identity was established on the basis of colony morphology and sugar assimilation tests (ID 32C assimilation profile). The fungemia and associated fever subsided after the removal of catheter and amphotericin B therapy. The data suggest that though of low virulence and usually a contaminant, C. lipolytica is emerging yeast pathogen in cases of catheter-related candidemia. Pathogenicity is indicated by isolation from repeated samples as in our case. Intensive therapy is recommended in cases not resolving spontaneously or responding to removal of catheter alone.

Cryptococcus gattii fungemia: report of a case with lung and brain lesions mimicking radiological features of malignancy

A 64-year-old apparently immunocompetent white man developed lung and brain lesions of disseminated cryptococcosis. The radiologic features mimicked those of lung cancer metastatic to the central nervous system. C. gattii was recovered from cultures of bronchoalveolar lavage fluid, brain biopsy, and blood. The same fungus was recovered from pulmonary and brain specimens at autopsy. Serum and cerebrospinal fluid cryptococcal antigen tests were diagnostic in our case and should be included in the diagnostic evaluation of unexplained pulmonary and cerebral lesions. A literature search showed few reports of fungemia by this species of Cryptococcus, contrasting to C. neoformans.

Homem branco de 64 anos, aparentemente imunocompetente, desenvolveu lesões pulmonares e cerebrais por criptococose disseminada. Os achados radiológicos foram similares àqueles encontrados em pacientes com câncer de pulmão e metástase no sistema nervoso central. C. gattii foi isolado de cultivos de lavado broncoalveolar, biópsia cerebral e sangue. O mesmo fungo foi encontrado em fragmentos pulmonares e cerebrais obtidos da autópsia. Testes de antígeno no soro e no líquido cefalorraquidiano foram diagnóstico no nosso caso e devem ser incluídos na avaliação diagnóstica de lesões pulmonares e cerebrais indefinidas. Pesquisa na literatura mostrou poucos relatos de fungemia por esta espécie de Cryptococcus, contrastando com C. neoformans.

Cryptococcal meningoencephalitis diagnosed by blood culture.

Increase in cryptococcal infection has been noticed after acquired immunodeficiency syndrome pandemic. Cryptococcus neoformans can be isolated from blood in the process of dissemination to brain. We report a case of cryptococcal fungaemia in a patient whose cerebrospinal fluid was negative for Cryptococcus neoformans. Retrospective analysis revealed human immunodeficiency virus seropositivity of the patient. He was treated with amphotericin B and fluconazole. Antiretroviral therapy was started, however, the patient succumbed to the infection.

Histoplasma capsulatum fungemia in patients with acquired immunodeficiency syndrome: detection by lysis-centrifugation blood-culturing technique

Progressive disseminated histoplasmosis (PDH) is an increasingly common cause of infection in patients with acquired immune deficiency syndrome (AIDS). We report 21 cases of PDH associated with AIDS diagnosed by lysis-centrifugation blood culture method. The most prevalent clinical findings were fever, weight loss, respiratory symptoms, and mucocutaneous lesions. Chest roentgenogram showed diffuse pulmonary infiltrates in 13 of 21 patients (62 percent). Brochoalveolar fluid has yelded positive culture in four patients only in medium with cycloheximide.

Histoplasmose progressiva disseminada (HPD) tem aumentado e é causa comum de infecção em pacientes com síndrome da imunodeficiência adquirida (Aids). Relatamos 21 casos de HPD associado com Aids diagnosticada pela técnica de hemocultivo por lise-centrifugação. Os achados clínicos mais prevalentes foram febre, perda de peso, sintomas respiratórios e lesões mucocutâneas. Raios X de tórax mostrou infiltrados pulmonares difusos em 13 dos 21 pacientes (62 por cento). Amostras de lavado broncoalveolar foram positivos em apenas 4 pacientes através de meio com cicloheximida.

Evaluation of polymerase chain reaction for the detection of Paracoccidioides brasiliensis DNA on serum samples from patients with paracoccidioidomycosis

The aim of this study was to demonstrate the DNA of Paracoccidioides brasiliensis in human serum samples of patients with paracoccidioidomycosis using the polymerase chain reaction (PCR). The diagnosis of paracoccidioidomycosis (PCM) was defined by microscopic observation of the fungus on direct exam or histopathology, culture, and serological positivity. DNA from serum of 33 patients with PCM was extracted and submitted to nested-PCR using primers from the gp 43 gene. Only one sample was positive on nested-PCR. We conclude that the prevalence of fungemia in patients with different clinical forms of PCM is low, limiting the use of serum DNA detection as an alternative diagnostic tool.

Candidemia in a Brazilian hospital: the importance of Candida parapsilosis

O presente estudo objetivou desenvolver uma análise retrospectiva de casos de candidemia em hospital brasileiro na cidade de Fortaleza, Ceará. Um total de 50 hemoculturas foram analisadas de 40 pacientes com quadros de candidemia. O diagnóstico micológico foi baseado na análise morfológica e bioquímica e os dados dos pacientes foram coletados das histórias clínicas. As espécies mais freqüentes foram Candida parapsilosis (n = 18), seguida por C. albicans (n = 14), C. tropicalis (n = 8), C. guillermondii (n = 6), C. glabrata (n = 2) e Candida spp. (n = 2). Um estudo descritivo foi realizado com apenas 21 pacientes os quais possuíam dados clínicos completos. Os episódios de candidemia aconteceram em oito pacientes do sexo masculino e 13 do feminino. Os fatores de risco implicados em candidemia foram antibioticoterapia prévia, uso de cateter venoso central, nutrição parenteral, sondagem gástrica e ventilação mecânica. A morte aconteceu em 13 dos 21 pacientes com candidemia. Este estudo demonstrou a emergência de candidemia causada por C. parapsilosis em um hospital brasileiro na cidade de Fortaleza, Ceará.

Disseminated penicillium marneffei infection with fungemia and endobronchial disease in an AIDS patients in China

To present a rare Chinese case ofdisseminated Penicilliummarneffei infection with fungemia and endobronchial disease in an AIDS patient. A 26-year-old policeman who had resided in Guangxi Province, China, for 3 years presented to his county hospital with a 2-month history of high fever and cough. A provisional diagnosis of pulmonary tuberculosis [TB] was made. Accordingly, the patient was treated with anti-TB drugs for 1 month but with no clinical improvement; he was then referred toWest China Hospital. Blood and bone marrow cultures as well as a bronchoscopic biopsy were positive for P. marneffei. A confirmatory serologic test for HIV was positive. A combination therapy with amphotericin B and itraconazole was instituted, and the patient responded well to treatment. This case showsendobronchial involvement caused by an emerging fungal microorganism. HIV-positive patients with a history of residence in or travel to southern China and a clinical presentation suggestive of TB but responding poorly to anti-TB treatment may have P. marneffei infection

Brote de cándida parapsilosis en una unidad de trasplante de médula ósea / An outbreak of candida parapsilosis at the bone marrow trasplantation unit

Cándida parapsilosis (Cp) ha sido asociada con infecciones en pacientes hospitalizados e inmunocomprometidos. El propósito de este estudio fue determinar algunos aspectos epidemiológicos de un brote de Cp en nuestra unidad de transplante de médula ósea (UTMO). Identificamos 3 pacientes con cultivos negativos iniciales y que adquirieron Cp luego de su admisión en UTMO. El germen fue aislado en hemocultivos y catéteres de los 3 pacientes, sobre un total de 5 pacientes internados en ese mes. Se comenzó el estudio para analizar los factores de riesgo de adquisición de Cp. La edad de los pacientes er de 8, 8 y 12 años, 2 pacientes eran de sexo masculino. El trasplante fuel allogénico en los 3 p, 2 p estaban con alimentación parenteral y todos habían recibido antibióticos. Las manos del personal de salud y seleccionadas zonas del medio ambiente fueron cultivadas. Cp fue aislada de las manos de una axiliar de servicoi. El análisis genómico por Random PCR demostró homología de los 4 aislamientos (3 pacientes y el personal) sugiriendo un origen clonal del brote. Las medidas de control de infecciones se enfatizaron y la auxiliar fue removida de la unidad. No se diagnosticaron nuevos brotes hasta el presente La hipótesis es uqe las manos de la auxiliar de servicio fueron el reservorio que favoreció el brote. En conclusión este reporte confirma que Cp puede trasmitirse intranosocomialmente en pacientes de alto riesgo. La tipificación molecular y las medidas de control de infecciones pueden ser útiles en evitar los brotes.

Oral itraconazole in treatment of candidemia in a pediatric intensive care unit.

OBJECTIVE: To examine efficacy of itraconazole in the treatment of candidemia in critically ill children. METHODS: We studied retrospectively cases of candidemia seen consecutively in our Pediatric Intensive Care Unit (PICU) over three and half years. Candida isolates from those patients included. Candida albicans--19, C. tropicalis--31, C. guillermondii--9, C.krusei--4 and C. glabrata--1. RESULTS: Of the 64 patients, 48 (75%) had symptoms suggestive of septicemia and 16 had no symptoms suggestive of septicemia. No antifungal therapy was given to asymptomatic patients; they recovered from candidemia without development of any sequelae. Of the 48 symptomatic patients 11 died before results of fungal culture became available and antifungal therapy could be started. Thirty seven patients were treated with itraconazole (10 mg/kg/day orally or through gastric tube). Seven (18.9 %) of 37 patients died, 3 within first week of antifungal therapy. Thirty (81%) patients recovered; microbiological cure was noted on average by day 14 (range 4-30 days). The mean +/- SD duration of therapy in patients who responded was 24 +/-7 days (range 21-42 days). None had any major side effect. CONCLUSION: We conclude that oral itraconazole may be effective in treatment of candidemia in children in a PICU where non-C. albicans candida species constituted majority (70%) of all Candida isolates.