Una experiencia de siete años en el laboratorio de Micología del Hospital de Pediatría Juan P. Garrahan / A seven-year experience in the Mycology Laboratory of Hospital de Pediatría Juan P. Garrahan

En noviembre del año 2015 nos incorporamos al Laboratorio de Micología del Servicio de Microbiología del Hospital Garrahan. En este breve resumen queremos compartir los avances logrados a través de nuestra experiencia durante siete años de trabajo profesional. Debido a los diagnósticos realizados y su complejidad, consideramos que el Hospital Garrahan, sus pacientes y la comunidad toda necesitan contar con un laboratorio de Micología que responda a sus necesidades. Creemos haber iniciado un camino que esperamos continúe y culmine con la creación de la Unidad de Micología (AU)

In November 2015 we joined the Mycology Laboratory of the Microbiology Service of the Hospital Garrahan. In this brief summary we want to share the advances achieved through our experience during seven years of professional work. Due to the diagnosis made and their complexity, we believe that the Hospital Garrahan, its patients and the entire community, need to have a Mycology laboratory that responds to their requirements. We believe we have started a path that we hope will continue and culminate with the creation of the Mycology Unit (AU)

COVID-19 associated rhinomaxillary mucormycosis: a case series and review of literature

During COVID-19 pandemic, fulminant deep fungal infection started emerging in India, known as Mucormycosis. This type of mucormycosis was termed as COVID-19 associated mucormycosis (CAM). These patients had previous history of COVID-19 infection. Such cases were mainly reported in immunocompromised patients such as patients with poorly controlled diabetes and chronic renal diseases etc. Rhinomaxillary mucormycosis is an aggressive, fulminant, fatal deep fungal infection of head and neck region. Early diagnosis and prompt treatment can reduce the mortality and morbidity associated with the disease; hence we present case series of rhinomaxillary mucormycosis to create awareness amongst dental surgeons

Multiparametric assay of screening for the diagnosis of mycoses of interest in Public Health: standardization of methodology / Ensaio multiparamétrico de triagem para diagnóstico de micoses de interesse em Saúde Pública: padronização da metodologia

The standardization and validation of a multiplex assay requires the combination of important parameters such as sensitivity and specificity, acceptable levels of performance, robustness, and reproducibility. We standardized a multiparametric Dot-blot aimed at the serological screening of paracoccidioidomycosis, histoplasmosis, and aspergillosis. A total of 148 serum were evaluated: 10 from healthy subjects, 36 from patients with paracoccidioidomycosis, 62 from patients with histoplasmosis, and 40 from patients with aspergillosis. It was found that the multiparametric Dot-blot showed a high percentage of cross-reactivity. However, when evaluated individually, in the serological screening of histoplasmosis, a good performance was observed when compared to the double immunodiffusion assay, considered the gold standard test, with 100% co-positivity and 83.3% co-negativity. The performance of serological screening for aspergillosis was not satisfactory when compared to double immunodiffusion, showing 71.4% co-positivity and 100% co-negativity. The evaluation of the stability of nitrocellulose membranes showed that membranes sensitized with H. capsulatum antigen remained stable for 90 days and those sensitized with A. fumigatus antigen for 30 days. We conclude that the use of crude antigens was not suitable for the standardization of the multiparametric Dot-blot assay, due to the high cross-reactivity, and that further tests should be performed with purified proteins (AU).

A padronização e validação de um ensaio multiplex requer a combinação de parâmetros importantes, como sensibilidade e especificidade, níveis aceitáveis de desempenho, robustez e reprodutibilidade. Este trabalho padronizou um Dot-blot multiparamétrico visando a triagem sorológica da paracoccidioidomicose, histoplasmose e aspergilose. Foram avaliadas 148 amostras de soro: 10 de indivíduos saudáveis, 36 de pacientes com paracoccidioidomicose, 62 de pacientes com histoplasmose e 40 de pacientes com aspergilose. Verificou-se que o Dot-blot multiparamétrico apresentou elevado percentual de reatividade cruzada. Entretanto, quando avaliado individualmente, na triagem sorológica da histoplasmose observou-se bom desempenho quando comparado ao ensaio de imunodifusão dupla, considerado o teste padrão ouro, com 100% de co-positividade e 83,3% de co-negatividade. O desempenho da triagem sorológica da aspergilose não foi satisfatório quando comparado a imunodifusão dupla, apresentando 71,4% de co-positividade e 100% de co-negatividade. A avaliação da estabilidade das membranas de nitrocelulose mostrou que membranas sensibilizadas com antígeno de H. capsulatum permaneceram estáveis por 90 dias e as sensibilizadas com antígeno de A. fumigatus, por 30 dias. Concluímos que o uso de antígenos brutos não foi adequado para a padronização do ensaio de Dot-blot multiparamétrico, devido ao alto índice de reatividade cruzada, e que novos testes devem ser realizados com proteínas purificadas (AU).

Diagnóstico micológico por técnicas no convencionales en el siglo XXI / Mycological diagnosis by non-conventional techniques in the 21st century

Introducción: En la actualidad las infecciones fúngicas representan un problema para la salud humana. Las infecciones causadas por especies patógenas de hongos registran un incremento constante y se ubican entre el cuarto y décimo lugar como causa de muerte, particularmente en las unidades de cuidado intensivo. Un diagnóstico adecuado y precoz impacta directamente en la morbilidad y mortalidad asociadas a estas. Objetivo: Describir las principales técnicas de diagnóstico no convencional de las enfermedades fúngicas más frecuentes, en especial las relacionadas con el diagnóstico serológico y molecular. Métodos: Se realizó una revisión de la literatura científica sobre el tema, publicada entre 2000 y 2019. Se revisaron un total de 63 trabajos. Como motores de búsqueda se emplearon Google y Google Scholar. Se revisaron las bases de datos Medline, PubMed, Science Direct, BUCea y SciELO. Análisis y síntesis de la información: Las técnicas serológicas se emplean en el diagnóstico de las micosis invasivas o sistémicas por ser fáciles, rápidas y confiables. La detección de anticuerpos tiene utilidad limitada en el diagnóstico de las micosis invasivas debido a que la respuesta puede estar retrasada, reducida o no existir en pacientes inmunocomprometidos. La detección de componentes no antigénicos liberados por los hongos durante la infección y la secuenciación de ácidos nucleicos fúngicos son otras opciones para el diagnóstico de las micosis. Conclusiones: El desarrollo biotecnológico aporta nuevas herramientas que incrementan las oportunidades de identificación de las micosis. En la actualidad se disponen de métodos basados tanto en la detección de marcadores inmunológicos como de elementos moleculares específicos. La eficacia de las herramientas no convencionales para el diagnóstico depende de la correcta combinación de estas(AU)

Introduction: Fungal infections are a current human health problem. Infections caused by pathogenic fungal species constantly increase in number, and are ranked between the fourth and tenth leading causes of death, particularly in intensive care units. Early accurate diagnosis has a direct impact on the morbidity and mortality of fungal infections. Objective: Describe the main non-conventional diagnostic techniques for the most common fungal diseases, especially those related to serological and molecular diagnosis. Methods: A review was conducted of the scientific literature about the topic published between the years 2000 and 2019. A total 63 publications were reviewed. The search engines used were Google and Google Scholar. The databases Medline, PubMed, Science Direct, BUCea and SciELO were reviewed. Data analysis and synthesis: Serological techniques are used for the diagnosis of invasive or systemic mycoses because they are easy, fast and reliable. The detection of antibodies has a limited usefulness in invasive mycosis diagnosis, for the response may be delayed, reduced or inexistent in immunocompromised patients. Detection of non-antigenic components released by fungi during infection and sequencing of fungal nucleic acids are other mycosis diagnosis options. Conclusions: Biotechnological development contributes new tools increasing mycosis identification opportunities. Methods are currently available which are based on detection of immunological markers and specific molecular elements. The efficacy of non-conventional diagnostic tools depends on their appropriate combination(AU)

Método convencional para o diagnóstico de micoses: um estudo comparativo / Conventional method for the diagnosis of mycoses: a comparative study

Introdução: O método clássico para o diagnóstico de micoses é realizado pelo Exame Micológico Direto (EMD) e cultural, que possibilita a visualização de estruturas fúngicas vegetativas e estruturas reprodutivas, respectivamente. Essa combinação é fundamental para reduzir possíveis erros analíticos e aumentar a precisão do diagnóstico. Métodos: Com a finalidade de verificar a frequência do EMD e cultural, e comparar seus parâmetros de sensibilidade e especificidade, realizamos uma análise retrospectiva entre janeiro de 2018 e maio de 2020, de 1603 laudos micológicos oriundos de um laboratório de análises clínicas, localizado em Porto Alegre. Resultados: Após a análise dos laudos observamos que a maioria dos casos apresentaram o EMD negativo com cultura positiva (36,24%). Na sequência, 30,87% dos casos foram de amostras negativas e 25,57% dos laudos foram positivos para ambos os exames. A minoria dos casos (7,29%) apresentou o EMD positivo com cultura negativa. Conclusão: Esta análise revelou que o exame cultural é mais sensível e específico, demonstrando uma maior confiabilidade no diagnóstico. Entretanto, vale ressaltar que a realização dos exames em conjunto, além de reduzir possíveis erros analíticos, proporciona um diagnóstico melhor fundamentado. (AU)

Introduction: The classic method for the diagnosis of mycoses is performed by both direct mycological examination (DME) and culture, which allow the visualization of vegetative and reproductive fungal structures, respectively. This combination is essential to reduce possible analytical errors and increase the accuracy of the diagnosis. Methods: To assess the frequency of DME and culture, and compare their parameters of sensitivity and specificity, we performed a retrospective analysis of 1603 mycological reports produced between January 2018 and May 2020 in a clinical analysis laboratory in Porto Alegre, southern Brazil. Results: After analyzing the reports, we observed that most cases presented a negative DME and a positive culture (36.24%). Subsequently, 30.87% of the cases were negative for both tests, and 25.57% were positive for both tests. The minority of cases (7.29%) presented a positive DME and a negative culture. Conclusion: Our analysis revealed that cultural examination is more sensitive and specific, showing greater reliability in the diagnosis. However, it is noteworthy that performing the tests together, in addition to reducing possible analytical errors, provides a more consistent diagnosis. (AU)

Causes of equine abortion, stillbirth, and perinatal mortality in Brazil / Causas de abortamento, natimortalidade e mortalidade em equinos no Brasil

Abortion and complications in reproduction are important causes of economic loss in horse breeding. Studies of its causal agents can help to identify the primary pathogens or other factors involved and define appropriate measures to reduce its occurrence. This research aimed to investigate the primary causes of equine abortion, stillbirth, and perinatal mortality in regions of Brazil. Tissue from aborted fetuses, stillbirths, neonates and foals submitted to the Biological Institute of São Paulo, Brazil, from January 2010 to July 2013 were processed for viral and bacterial isolation, polymerase chain reaction (PCR), histology, and immunohistochemistry. Bacterial infection was the primary detected cause of abortion, found in 16 of the 53 animals submitted for bacterial analysis followed by viruses analysis in 2 of 105 animals, and noninfectious causes (neonatal isoerythrolysis) in 2 of 105 animals. Fungi were found in a single sample of 53 tested. The most frequent bacteria recovered were Escherichia coli, Enterobacter aerogenes, combined E. coli and Streptococcus spp., Staphylococcus spp., and Bacillus spp. The following agents were each observed in a single sample: Arcanobacterium pyogenes, Streptococcus spp., Corynebacterium spp., Actinobacillus spp., and Rhodococcus equi. The predominant identification of fecal and other opportunistic bacteria as opposed to pathogens commonly associated with equine abortion, such as Leptospira spp. and equine herpesvirus type 1 (EHV-1), suggests the need of improving hygiene management of breeding mares to prevent bacterial infection that may cause fetal loss, stillbirth, and perinatal mortality.(AU)

Abortamento e complicações na reprodução são importantes causas de perda econômica na equideocultura. Estudos dos agentes causais podem ajudar a identificar patógenos ou outros fatores envolvidos e definir medidas apropriadas para reduzir sua ocorrência. Esta pesquisa investigou as causas primárias de aborto, natimortalidade e mortalidade perinatal em equinos de diversas regiões do Brasil. Tecidos de fetos abortados, natimortos e potros submetidos ao Instituto Biológico de São Paulo, Brasil, no período de janeiro de 2010 a julho de 2013, foram processados por meio de técnicas de isolamento viral e bacteriano, PCR, histologia e imuno-histoquímica. Infecção bacteriana foi a causa mais detectada, encontrada em 16 de 53 amostras submetidas à análise bacteriana, seguida de causa viral em 2 de 105 amostras, e causas não infecciosas (isoeritrólise neonatal) em 2 de 105 amostras. Fungo foi encontrado em uma única amostra de 53 testadas. As bactérias isoladas mais frequentemente foram Escherichia coli, Enterobacter aerogenes, E. coli associada a Streptococcus spp., Staphylococcus spp. associado a Bacillus spp. Os seguintes agentes foram observados em uma única amostra cada: Arcanobacterium pyogenes, Streptococcus spp., Corynebacterium spp., Actinobacillus spp. e Rhodococcus equi. A identificação predominante de bactérias fecais e outras bactérias oportunistas, ao invés de outros patógenos comumente associados a quadros de abortamento equino, tais como Leptospira spp. e Herpesvírus equino tipo 1, sugere a necessidade de maior atenção no manejo higiênico das éguas em reprodução, a fim de prevenir infecções bacterianas que possam causar perda fetal, natimortalidade e mortalidade perinatal.(AU)

Molecular identification of clinical isolates of Fusarium in Colombia / Identificación molecular de aislamientos clínicos de Fusarium en Colombia

ABSTRACT Objective Identifying Fusarium isolates from mycosis symptomatic patients through molecular techniques as PCR and sequencing. Methods In this study, samples were taken from 101 mycosis symptomatic patients in-between 2004-2006. To determine isolates belonging to the Fusarium genus, the DNAr 28S region was amplified through PCR and specific PCR primers further confirmed their identity to the species level. Additionally, in order to confirm the identity of the species of the isolates, 75 isolates of these were analyzed by partial sequencing of the 28S rDNA and the TEF1-α gene. Results The 28S rDNA portion detected all 101 isolates as belonging to Fusarium and the PCR specific primers detected 52 and 29 isolates as F. oxysporum and F. solani, respectively; 34 and 41 of these, afterwards studied by partial sequencing of the 28S rDNA and TEF1- α genes respectively, were effectively identified by the technique. Conclusion From all the molecular markers used to identify Fusarium isolates, the sequence of the TEF1-α gene provided the best resolution in the identification of species level; however it is possible to discriminate between F. oxysporum and F. solani isolates by PCR, in most of the cases, what is important considering the simplicity of the technique and a faster diagnosis.(AU)

RESUMEN Objetivo Identificar aislamientos de Fusarium en pacientes con micosis por medio de las técnicas moleculares de PCR y secuenciación. Métodos Se tomaron 101 muestras de pacientes con micosis sintomática, entre los años 2004 y 2006. Para la detección de aislamientos como pertenecientes al género Fusarium, se amplificó parcialmente por PCR la región 28S del DNAr; y posteriormente -para la detección de la especie de Fusarium- se utilizaron cebadores específicos para F. oxysporum y F. solani. La verificación de la identidad de la especie de los aislamientos se hizo por secuenciación parcial de los genes 28S DNAr y TEF1-α Resultados El total de 101 aislamientos fueron detectados como pertenecientes al género Fusarium utilizando un cebador universal de la region 28S DNAr; 52 y 29 aislamientos se detectaron como F. oxysporum o F. salani, respectivamente con los cebadores específicos, y la secuenciación parcial de los genes 28S rDNA o TEF1-α confirmó la identidad de las especies. Conclusión La secuenciación parcial del gen TEF1-α es aún el mejor marcador molecular para identificar aislamientos de Fusarium a nivel de especie. Sin embargo, en la mayoría de los casos es posible discriminar entre aislamientos de F. oxysporum y F. solani por PCR con cebadores específicos, lo que proporciona una ventaja importante considerando la simplicidad de la técnica y el rápido diagnóstico.(AU)

Oral Manifestations Associated to Paracoccidioidomicosis and Histoplasmosis

Objective: To determine the frequency and clinical forms of oral manifestations associated to Paracoccidioidomycosis (PCM) and Histoplasmosis. Material and Methods: 481 medical records of outpatients referred to the Medical Mycology Department were reviewed since 2009 to 2016. Data were analyzed using descriptive statistical methods. Results: 47 (9.77%) cases had oral manifestations, 29 (61.70%) were associated to PCM and 18 (38.29%) to histoplasmosis. For PCM, male-female ratio was 8:1 and 1:1 for histoplasmosis. The average age for PCM was 48 years old and 53 for histoplasmosis. All the PCM patients had more than 1 oral structure affected: 44.82% were gingival lesions and 27.58% palate. In patients with histoplasmosis, 6 (33.33%) were lesions affecting palate and 6 (33.33%) involving tongue. For both entities, painful ulcers and granulomatous-like lesions were the most prevalent clinical forms; however, we observed a wide range of other oral manifestations. Regarding PCM patient's comorbidities, 3 (10.34%) cases had HIV/AIDS, 8 (27.58%) histoplasmosis and 2 (6.89%) carcinomas. Whereas the comorbidities of patients with histoplasmosis, 2 (11.11%) had HIV/AIDS and 1 (5.55%) had carcinoma. Conclusion: In endemic countries for both mycoses, dentists must be aware of patients with mouth lesions, take advantage of epidemiologic clues that suggest risk factors and be acquainted with all the current diagnostic tests in order to make a quick diagnosis and treatment in highly suspicious cases.

Patient in chronic hemodialysis with right atrial mass: thrombus, fungal endocarditis or atrial myxoma? / Paciente em hemodiálise crônica com massa em átrio direito: trombo, endocardite fúngica, ou mixoma atrial?

Abstract We present the case report of a 19-year-old patient with chronic kidney disease due to chronic glomerulonephritis, in hemodialysis (HD) by central catheter, with the incidental finding of a mass of 28x16 mm in right atrium (RA). The diagnosis of thrombus, infective endocarditis or myxoma were considered. Given the context of immunosuppression and difficult access vascular therapeutic practice has proved complex. Although Doppler echocardiography suggested thrombus in RA, nuclear magnetic resonance imaging (MRI) indicated for the diagnosis of myxoma in RA. In both conditions, the proposed surgical approach was limited by intense immunosuppression history and the risk of infectious complications. Throughout the treatment, the general state of K.M.F. remained satisfactory and revealed no signs or symptoms related to atrial dysfunction. The absence of fever and negative blood cultures excluded infective endocarditis. Prior echocardiogram report without masses in the RA decreased the chance of cardiac myxoma. The therapeutic response to anticoagulation confirmed the diagnosis of thrombosis. After 180 days of anticoagulation, there was significant reduction in mass. The patient developed asymptomatic. The diagnosis of mass in RA can be a challenge and only the evolution of the case was able to guide the appropriate conduit. While MRI has high sensitivity and specificity for the diagnosis of cardiac myxoma, the interpretation of images can be subjective. Controversial point is the removal of the catheter in such cases, which is subject discussed throughout the report.

Resumo Apresentamos o relato de caso de uma paciente de 19 anos com doença renal crônica devido à glomerulonefrite crônica e em hemodiálise (HD) por cateter central, com o achado incidental de uma massa de 28x16 mm em átrio direito (AD). Foram considerados os diagnósticos de trombo, endocardite infecciosa ou mixoma. Devido ao contexto de imunossupressão e dificuldade de acesso vascular, a condução terapêutica revelou-se complexa. Apesar de Ecodopplercardiograma sugerir trombo em AD, imagens de ressonância nuclear magnética (RNM) apontaram para o diagnóstico de mixoma em AD. Nas duas condições a proposta de abordagem cirúrgica esteve limitada pelo histórico de imunossupressão intensa e o risco de complicações infecciosas. Ao longo do tratamento, o estado geral de K.M.F. manteve-se satisfatório e não foram observados sinais ou sintomas relacionados a disfunção atrial. A ausência de febre e hemoculturas negativas excluíram endocardite infecciosa. O relato de ecocardiograma prévio sem massas em AD tornou menor a possibilidade de mixoma cardíaco. A resposta terapêutica à anticoagulação confirmou o diagnóstico de trombo. Após 180 dias de anticoagulação, houve redução significativa da massa. A paciente evoluiu assintomática. O diagnóstico de massa em AD pode ser um desafio e somente a evolução foi capaz de guiar a conduta apropriada. Apesar da RNM ter elevada sensibilidade e especificidade para o diagnóstico de mixoma cardíaco, a interpretação de imagens pode ser subjetiva. Ponto controverso é a retirada de cateter nesses casos, que é assunto discutido ao longo do relato.

Infección por Kodamaea ohmeri en un recién nacido con una masa mediastinal / Kodamaea ohmeri infection in a newborn with a mediastinal mass

Las infecciones por hongos son una causa de morbilidad y mortalidad, lo que lleva a un incremento de la estancia hospitalaria y a un aumento de los costos en salud, en el período neonatal. Durante este período, los prematuros son los más afectados. Las especies Candida son la causa principal de infección fúngica. La mayoría son causadas por C. albicans, C. parapsilosis, C. glabrata y C. tropicalis, aunque otras especies han sido reportadas. Una de ellas, como un patógeno emergente, es K. ohmeri. Este organismo ha sido reportado como patógeno en el período neonatal, principalmente en prematuros. Los factores de riesgo asociados a infección fúngica son accesos venosos centrales, inmunosupresión, larga estancia hospitalaria, intubación endotraqueal y uso de antibióticos. Presentamos a un neonato con una masa mediastinal, quien requirió múltiples intervenciones, como pericardiocentesis, catéter central, ventilación mecánica y antibióticos. Durante su evolución, presentó infección por K. ohmeri. Fue tratado con anfotericina B, con evolución clínica satisfactoria.

Invasive fungal infections are a considerable cause of morbidity, mortality, increased hospital stay durations, and high health care costs, during neonatal period. In this period, the premature infants are the most affected. Candida species are the leading cause of invasive fungal infections. The majority of neonatal Candida infections are caused by C. albicans, C. parapsilosis, C. glabrata and C. tropicalis, although other fungus species are being reported. One such emerging pathogen is K. ohmeri. This organism has been reported as a pathogen in the neonatal period, principally in premature infants. The risk factors associated with fungal infection are central line, immunosuppression, prolonged hospital stay, endotracheal intubation and exposure to antibiotics. We present a term baby with a mediastinal mass, who required several procedures, as pericardiocentesis, central catheters, mechanical ventilation, antibiotics. During his evolution, he presented infection by K. ohmeri. The baby was treated with amphotericin B, with satisfactory clinical course.

Fungal endocarditis

ABSTRACT Fungal endocarditis is a rare and fatal condition. The Candida and Aspergillus species are the two most common etiologic fungi found responsible for fungal endocarditis. Fever and changing heart murmur are the most common clinical manifestations. Some patients may have a fever of unknown origin as the onset symptom. The diagnosis of fungal endocarditis is challenging, and diagnosis of prosthetic valve fungal endocarditis is extremely difficult. The optimum antifungal therapy still remains debatable. Treating Candida endocarditis can be difficult because the Candida species can form biofilms on native and prosthetic heart valves. Combined treatment appears superior to monotherapy. Combination of antifungal therapy and surgical debridement might bring about better prognosis.

Presentación de siete casos de tiña negra en niños / Reports of seven cases of tinea nigra in children

Introducción: la tiña negra es una micosis superficial causada por el hongo Hortaea werneckii. Se considera una micosis benigna que por lo general es observada en países tropicales. Objetivo: reportar siete casos de tiña negra en niños de dos hospitales de La Habana, Cuba. Métodos: se realizó estudio micológico (examen directo y cultivo) a partir de escamas tomadas mediante raspado de las lesiones a siete niños con diagnóstico clínico presuntivo de tiña negra palmar. Se registraron las características de las lesiones, edad, sexo y factores predisponentes de los pacientes, así como la evolución del cuadro con el tratamiento antifúngico. Resultados: se confirmó la sospecha clínica de tiña negra a través del aislamiento e identificación de Hortae werneckii. Las edades de los pacientes oscilaron entre 3 y 6 años y el 57 por ciento era del sexo femenino. La hiperhidrosis se encontró en el 43 por ciento de los casos. El tratamiento específico con antifúngicos azólicos y terbinafina tópicos fue satisfactorio en 21 días como promedio. Conclusiones: todos los casos con sospecha de tiña negra fueron confirmados de manera oportuna en el laboratorio, lo que permitió descartar enfermedades malignas y aplicar tratamiento específico(AU)

Rare severe mycotic infections in children receiving empirical caspofungin treatment for febrile neutropenia

ABSTRACTEmpirical antifungal therapy is most often given to patients with leukemia. However breakthrough fungal infections under antifungal therapy are not uncommon. Four children, with hematologic malignant disease developed mycotic breakthrough infections while on empirical caspofungin treatment for a median of 14 (range 11-19) days. Trichosporon asahii was detected in the blood culture of two patients and Geotrichum capitatum in the other two (one patient also had positive cerebrospinal fluid culture). Because the patients' clinical situation worsened, voriconazole was empirically added for two patients three and five days before the agent was detected. The first sterile blood culture was obtained 3-7 days of voriconazole treatment. All patients reached clear cultures but one patient died. One patient with central nervous system infection with G. capitatum had severe neurological sequelae. Very severe fungal infections can occur during empirical caspofungin therapy. Therefore, patients should be followed closely.

PCR-RFLP as a useful tool for diagnosis of invasive mycoses in a healthcare facility in the North of Brazil

Background The incidence of invasive mycoses is increasing worldwide. PCR-RFLP was applied to the identification of 10 reference strains and 90 cultures of agents of invasive mycoses. In addition, the new approach was applied to detect fungal agents in 120 biological samples (blood, cerebrospinal fluid and bone marrow). PCR-RFLP results were compared with the ones obtained with conventional methods (culture, microscopy, and biochemical testing). Results The assays carried out with the reference strains (Candida albicans, Candida parapsilosis, Candida tropicalis, Candida krusei, Candida guilliermondii, Cryptococcus neoformans, Cryptococcus gattii and Histoplasma capsulatum), demonstrated that the RFLP profiles were correctly predicted by the in silico investigation and allowed unequivocal identification of all chosen reference strains. The PCR-RFLP also identified 90 cultures of agents of invasive mycoses correctly, 2.5 times faster than the conventional assays. Evaluating PCR-RFLP with biological samples it was observed that the PCR was found to be 100% accurate and the RFLP profiles allowed the identification of the etiological agents: C. neoformans (n = 3) and C. gattii (n = 1) in CSF samples, H. capsulatum (n = 1) in bone marrow and C. albicans (n = 2) in blood cultures. The detection and identification by PCR-RFLP were found to be between two to ten times faster than the conventional assays. Conclusion The results showed that PCR-RFLP is a valuable tool for the identification of invasive mycoses that can be implemented in hospital laboratories, allowing for a high number of clinical analyses per day.

Enfermedad fúngica invasora (EFI) por hongos filamentosos en la Región de Valparaíso, Chile, desde la implementación del diagnóstico rápido de laboratorio / Invasive fungal disease (IFD) by filamentous fungi in the Valparaíso Region, Chile, since implementation of rapid laboratory diagnosis

Introduction: Invasive fungal diseases (IFD) by filamentous fungi are a common cause of morbidity and mortality in immunocompromised patients, especially those with myeloid leukemia. In 2011 a protocol for the rapid diagnosis of IFD by filamentous fungi was implemented in Valparaiso Region. Objectives: To describe cases of IFD by filamentous fungi of the Valparaíso Region, since the implementation of rapid diagnosis and to compare results with the period 2004-2009. Materials and Method: Descriptive and prospective study conducted in two public hospitals: Carlos van Buren at Valparaiso and Gustavo Fricke at Viña del Mar. We selected patients with a diagnosis of filamentous fungal diseases considering the EORTC/MSG criteria. Demographics, underlying diseases, risk factors for EFI, galactomannan (GM) results in blood and bronchoalveolar lavage, cultures and biopsies, treatment and overall lethality rates at 30 days were registered. Results: Eighteen patients were detected, 6 with proven and 12 probable IFD. Nine were diagnosed by GM, 8 by culture and two with both methods. In cases which the agent (9/18) was isolated from Rhizopus oryzae was the most frequent. When comparing overall lethality with the period 2004-2009, there was a reduction of 47.8%, which was statistically significant. Conclusions: Compared to data previously published in the region, demographic and comorbidities of patients with IFD caused by filamentous fungi are similar, however the currently rapid diagnosis protocol has improved survival of patients and lethality experienced overall decrease.

Introducción: la enfermedad fúngica invasora (EFI) por hongos filamentosos es una causa frecuente de morbilidad y mortalidad en pacientes inmunocomprometidos, en especial en aquellos con leucemia mieloide. En el 2011 se implementó en la Región de Valparaíso un protocolo de diagnóstico rápido de la EFI por hongos filamentosos. Objetivos: describir los casos de EFI por hongos filamentosos de la Región de Valparaíso, desde la implementación del diagnóstico rápido y compararlos con el período 2004-2009. Materiales y Método: Estudio descriptivo y prospectivo realizado en los hospitales públicos Carlos van Buren de Valparaíso y Gustavo Fricke de Viña del Mar. Se seleccionaron aquellos pacientes con diagnóstico de EFI por hongos filamentosos considerando los criterios EORTC/MSG. Se obtuvieron datos demográficos, enfermedad de base, factores de riesgo para EFI, resultados de galactomanano (GM), cultivos y biopsias, tratamiento y letalidad global a 30 días. Resultados: Se identificaron 18 pacientes, seis con EFI probadas y 12 probables. Nueve fueron diagnosticados con galactomanano, ocho con cultivos y uno con los dos métodos. En los casos en que se aisló el agente (9/18), Rhizopus oryzae fue el más frecuente. Al comparar la letalidad global con la del período 2004-2009, hubo una reducción de 47,8%, la cual fue estadísticamente significativa. Conclusiones: En relación a lo publicado anteriormente en la región, se conservan las características demográficas y de co-morbilidad de los pacientes con EFI por hongos filamentosos; sin embargo, la introducción del nuevo protocolo de diagnóstico rápido se asoció a una disminución en la letalidad global.

Micosis superficiales: estudio retrospectivo de corte transversal en la ciudad de Córdoba, Argentina / Superficial mycoses: retrospective cross-sectional study in the city of Córdoba, Argentina

Las micosis superficiales son enfermedades que afectan de forma frecuente al ser humano. En la ciudad de Córdoba, Argentina, existe muy poca información acerca de las mismas.Por tal motivo se realizó un estudio retrospectivo, de corte transversal, con muestras de 2.855 pacientes, tomadas entre 2008 y 2009 en distintos tipos de centros asistenciales, con el fin de obtener datos epidemiológicos actualizados. Se incluyeron pacientesmayores de 15 años, de ambos sexos, residentes en la mencionada ciudad. El análisis estadístico se realizó con pruebas de bondad de ajuste chi cuadrado, con un nivel de significación del 5%. En los resultados se obtuvo un mayor porcentaje del sexo femenino enla concurrencia a laboratorios de micología, y la edad media fue de 44, 35 años. La topografía más frecuente en centros privados fueron las onicomicosis, mientras que en hospitales públicos se estudiaron con mayor frecuencia las afecciones de piel. Los estudiosmicológicos revelaron el 65,18% de exámenes directos con presencia de elementos fúngicos y en el 34,82% resultaron negativos. En hospitales públicos se detectó en el examendirecto el 15,72% de Malassezia spp., mientras que en centros privados el 7,89%. En los exámenes micológicos de cultivo se aislaron en mayor proporción dermatofitos del géneroTrichophyton,seguidos de levaduras no lipofílicas del género Candida. Por su parte, sedestacó que los pacientes que en mayor proporción asistieron a los centros asistenciales fueron de barrios cuyas necesidades básicas insatisfechas poseían un rango del 2,21% al 6,63%...

Estudio de micosis superficiales en la población de Villa del Prado, provincia de Córdoba, Argentina / Study of superficial mycoses in Villa del Prado population,province of Córdoba, Argentina

Las micosis superficiales son patologías frecuentes en la consulta dermatológica. Según la Organización Mundial de la Salud (OMS), alrededor del 20-25% de la población mundial padece micosis superficiales. Existe poca información de las mismas y en especial de zonas periurbanas. Nuestro objetivo fue obtener datos epidemiológicos acerca de las micosis superficiales e identificar sus agentes etiológicos que afectan piel, pelo y uñas en los pobladores de la comuna de Villa del Prado. El estudio fue descriptivo, prospectivo y transversal. Se incluyeron pacientes mayores de 2 años, con lesiones cutáneas y anexialesque sugirieron micosis superficiales, excluyéndose menores de 2 años, con hepatopatía previa al estudio y embarazadas. El proyecto del área de Responsabilidad Social Universitaria se realizó en los períodos lectivos 2008-2010. Los pacientes fueron atendidosen el dispensario de esa localidad por médicos dermatólogos y residentes. Las bioquímicas micólogas con alumnos de 4º año de la carrera de Bioquímica indicaban la preparación para la toma de muestra y extracción de la misma. Los análisis micológicos se llevarona cabo por metodología clásica. Se realizaron 41 viajes a dicha comunidad, 248 consultas dermatológicas y se atendieron 142 pacientes. Se detectaron 22 pacientes con lesiones micológicas y 19 concurrieron a la toma de muestras. El examen directo resultó positivo en 14 de ellos, uno de los cuales fue Malassezia spp. Los cultivos dieron positivo en 14 pacientes, dos de ellos con dos agentes etiológicos. Se obtuvieron: cuatro Trichophyton rubrum, tres Trichophyton mentagrophytes, cinco Candida albicans, una Candida tropicalis, un Epidermophyton floccosum, un Trichophyton interdigitale y unMicrosporum canis. La mayoría de los aislamientos pertenece al grupo de los dermatofitos, en segundo lugar levaduras del género Candida, y se detectó Malassezia spp.

Superficial mycosis are common dermatologic complaints. According to the World Health Organization (WHO) about 20-25% of the world population suffers from superficial mycosis.There is little information about them especially in peri-urban areas. Our aim was toobtain epidemiological data about superficial mycosis and to identify their etiologicalagents affecting the skin, hair and nails in the population of Villa del Prado community.Our study was descriptive, prospective and cross-sectional. We included patients olderthan 2 years old presenting skin and adnexal lesions suggesting superficial mycosis.Children under 2 years of age, with previous hepatic disease and pregnant women were excluded. The University Social Responsibility project was carried out during 2008-2009-2010 school years. Patients were assisted in Villa del Prado health care center by dermatologists and medical residents. Biochemists specialized in Mycology indicated the preparationfor taking samples to their fourth year students of the Career in Biochemistry.Mycological analyses were performed following the classical methodology. The team went41 times to the community receiving 248 dermatologic consultations; 142 patients wereassisted. In 22 patients mycological lesions were detected; 19 of them went to sampletaking. Direct testing was positive in 14 patients, Malassezia spp being one of them. Cultures were positive in 14 patients, two of them with 2 aethiological agents. 4Trichophyton rubrum, 3 Trichophyton mentagrophytes, 5 Candida albicans, 1 Candida tropicalis,1 Epidermophyton floccosum, 1 Trichophyton interdigitale y 1 Microsporum canis wereobtained. Most isolates belong to the dermatophytes group followed by yeasts of thegenus Candida and Malassezia spp was also detected.

Molecular Identification and Amphotericin B Susceptibility Testing of Clinical Isolates of Aspergillus From 11 Hospitals in Korea

BACKGROUND: We investigated the species distribution and amphotericin B (AMB) susceptibility of Korean clinical Aspergillus isolates by using two Etests and the CLSI broth microdilution method. METHODS: A total of 136 Aspergillus isolates obtained from 11 university hospitals were identified by sequencing the internal transcribed spacer (ITS) and beta-tubulin genomic regions. Minimal inhibitory concentrations (MICs) of AMB were determined in Etests using Mueller-Hinton agar (Etest-MH) and RPMI agar (Etest-RPG), and categorical agreement with the CLSI method was assessed by using epidemiological cutoff values. RESULTS: ITS sequencing identified the following six Aspergillus species complexes: Aspergillus fumigatus (42.6% of the isolates), A. niger (23.5%), A. flavus (17.6%), A. terreus (11.0%), A. versicolor (4.4%), and A. ustus (0.7%). Cryptic species identifiable by beta-tubulin sequencing accounted for 25.7% (35/136) of the isolates. Of all 136 isolates, 36 (26.5%) had AMB MICs of > or =2 microg/mL by the CLSI method. The categorical agreement of Etest-RPG with the CLSI method was 98% for the A. fumigatus, A. niger, and A. versicolor complexes, 87% for the A. terreus complex, and 37.5% for the A. flavus complex. That of Etest-MH was < or =75% for the A. niger, A. flavus, A. terreus, and A. versicolor complexes but was higher for the A. fumigatus complex (98.3%). CONCLUSIONS: Aspergillus species other than A. fumigatus constitute about 60% of clinical Aspergillus isolates, and reduced AMB susceptibility is common among clinical isolates of Aspergillus in Korea. Molecular identification and AMB susceptibility testing by Etest-RPG may be useful for characterizing Aspergillus isolates of clinical relevance.

Infections after lung transplantation: time of occurrence, sites, and microbiologic etiologies

BACKGROUND/AIMS: Infections are major causes of both early and late death after lung transplantation (LT). The development of prophylaxis strategies has altered the epidemiology of post-LT infections; however, recent epidemiological data are limited. We evaluated infections after LT at our institution by time of occurrence, site of infections, and microbiologic etiologies. METHODS: All consecutive patients undergoing lung or heart-lung transplantation between October 2008 and August 2014 at our institution were enrolled. Cases of infections after LT were initially identified from the prospective registry database, which was followed by a detailed review of the patients' medical records. RESULTS: A total of 108 episodes of post-LT infections (56 bacterial, 43 viral, and nine fungal infections) were observed in 34 LT recipients. Within 1 month after LT, the most common bacterial infections were catheter-related bloodstream infections (42%). Pneumonia was the most common site of bacterial infection in the 2- to 6-month period (28%) and after 6 months (47%). Cytomegalovirus was the most common viral infection within 1 month (75%) and in the 2- to 6-month period (80%). Respiratory viruses were the most common viruses after 6 months (48%). Catheter-related candidemia was the most common fungal infection. Invasive pulmonary aspergillosis developed after 6 months. Survival rates at the first and third years were 79% and 73%, respectively. CONCLUSIONS: Although this study was performed in a single center, we provide valuable and recent detailed epidemiology data for post-LT infections. A further multicenter study is required to properly evaluate the epidemiology of post-LT infections in Korea.

Guía para el diagnóstico de laboratorio de enfermedad fúngica invasora por hongos filamentosos / Laboratory guidelines for diagnosis of invasive fungal disease caused by filamentous fungi

Early diagnosis and timely treatment are critical in Invasive Fungal Disease (IFD) caused by filamentous fungi in immunocompromised patients. Clinical features of IFD are nonspecific; therefore, images (CT scan), direct microscopic examination, staining and cultures of clinical samples and galactomannan determination in blood or BAL, are substantial. This guideline provides recommendations on transport and sample processing, including stains and culture media requirements. It also describes clues for diagnosis of major genera and species of Aspergillus.

La enfermedad fúngica invasora (EFI) por hongos filamentosos es causa de morbi-mortalidad en pacientes inmunocomprometidos, por lo que es fundamental el diagnostico precoz y su tratamiento oportuno. Las manifestaciones clínicas de las EFIs son inespecíficas, razón por la cual las imágenes (TAC), el examen microscópico directo, tinciones y cultivos de las muestras obtenidas y la determinación de galactomanano en sangre o en LBA tienen un rol fundamental. Esta guía tiene por objetivo recomendar las óptimas condiciones de transporte, procesamiento de las muestras, así como las tinciones y los medios de cultivos a utilizar. Se describen, además, claves para el diagnóstico de los principales géneros y especies de Aspergillus.