Pulmonary nocardiosis caused by Nocardia otitidiscaviarum in an adult asthmatic female patient: The presence of acid-fast branching filaments is always significant.

We report a case of pulmonary nocardiosis in a 41-year-old asthma patient. Chest radiographs showed bilateral air space and consolidations.Acid-fast branching filaments were demonstrated in sputum, and the grown organism was identified phenotypically and confirmed using16S rDNA sequencing (accession no. KX500116). The patient received a combination of medical treatments, but developed complications,which were managed over the next 3 months, after which she was discharged. Pulmonary nocardiosis should be considered in patientsundergoing steroid therapy or when a chronic infection does not respond to first-line treatment.

Nasosinus aspergillosis in Sudanese patients: clinical features, pathology, diagnosis, and treatment.

OBJECTIVE: The objective of this study was a prospective analysis of the clinical features, pathology, diagnosis, and treatment of patients treated between 1993 and 1996 for nasosinus aspergillosis in the Sudan. METHOD: Clinical examinations and laboratory tests for serologic, mycologic, and histologic analysis were conducted on all patients, as were radiologic and computerized tomographic studies when external swelling of any of the paranasal sinuses was evident. RESULTS: The age group 11 to 50 years were predominantly affected, with a peak in those aged 21 to 30 years. Females were affected more often than were males. The clinical features were mainly nasal polyposis, external swelling of the ethmoid sinus medial to the inner canthus, or maxillary cheek swelling and/or proptosis. In the paranasal sinuses, the ethmoids were the most frequently affected. Intracranial extension of the disease occurred in two patients. Serologic examinations and mycological cultures showed more incidence of positive results than did histopathology. Aspergillus flavus was grown in all the positive mycologic cultures except one, where Aspergillus niger was grown. The treatment was mainly surgical, supplemented by an antifungal drug (itraconazole). The incidence of recurrence was 9.3%, and it was noticed that the recurrence occurred in those patients who were not taking their medicines regularly. CONCLUSION: Nasosinus aspergillosis is a common disease in Sudan. Nasal polyposis is the commonest mode of clinical presentation. Serology and mycologic cultures are quite helpful in the diagnosis. Surgical and medical treatment are complementary of each other.

Nocardia, nocardiosis and mycetoma.

The recent emergence of invasive infections due to Nocardia spp., including nosocomial outbreak, is now evident. Newer molecular diagnostic and typing methods are developed. Although sulfonamide-based therapy is generally effective, optimal treatment may be guided by antimicrobial susceptibility testing of isolates. The improved classification of nocardiae and other related genera such as actinomadurae, using the 16S ribosomal RNA sequencing, provide a sound basis for improved diagnostic methods for the identification of members of clinically significant species. The commonest cause of eumycetoma in Sudan is Madurella mycetomatis, and Streptomyces somaliensis and Actinomadura madurae for actinomycetoma. The humoral immunity response in actinomycetoma patients and in experimental mice was measured and significant titre of anti-P24 antibody was demonstrated.

The host tissue reaction to Madurella mycetomatis: new classification.

In this prospective study, three types of tissue reaction to mycetoma grains are described. Type I reaction is characterized by the adherence of neutrophils to the surface of the grain leading to its disintegration. In Type II reaction, the fragmented grain and the dead neutrophils are cleared by macrophages and multinucleated giant cells, while in Type III reaction there is a discrete well developed epithelioid granuloma with Langhans's giant cells. The three types of reaction are usually seen in different combinations in the same lesion.

A preliminary study on the ultrastructure of Actinomadura pelletieri and its host tissue reaction.

This is the first report on the fine structure of Actinomadura pelletieri. The in vitro ultrastructure of the organism and that of the grain in vivo were similar. The grain consisted of packed filaments with a faintly electron-dense matrix in between. The individual filament was septate, the cytoplasm was either vacuolated or contained intracellular organelles and the cytoplasmic membrane was adherent to the filamentous wall, which has three electron-dense and two electron-lucent layers. The absence of cement substance around the grain may partially explain the aggressive and destructive behaviour of this organism and may probably also explain its good response to medical treatment. The inflammatory host reaction was similar to that seen with all mycetoma organisms except that there was a massive neutrophil reaction. This was confirmed by electron microscopy.

Post-operative responses of paranasal Aspergillus granuloma to itraconazole.

Paranasal Aspergillus granuloma is an invasive infection, seen mainly in tropical countries, involving the paranasal sinuses, orbit and brain. Previously surgical excision has been followed by a high relapse rate, 80% in some series, and mortality. This study involved the use of post-operative therapy with oral itraconazole in doses of 200-300 mg daily. Twenty-two patients were treated for a mean period of 19.7 weeks. Of 19 patients for whom follow-up data were available, 12 (62%) were rated as being in complete remission in a mean period of 17.2 months after the end of therapy. Only one patient developed progressive disease during itraconazole therapy. No serious adverse effect was seen. Use of itraconazole shows promise as a means of preventing relapse after surgery in this progressive infection.

In vitro studies of antibiotic sensitivities of Streptomyces somaliensis--a cause of human actinomycetoma.

Ten Streptomyces somaliensis strains isolated from mycetoma patients were tested in vitro against 13 antibacterial agents. Rifampicin was the most effective antibiotic in terms of low minimum inhibitory concentration (MIC) followed by erythromycin, tobramycin, fusidic acid and streptomycin sulphate. The S. somaliensis strains were all resistant to trimethoprim, even though the combination of sulphamethoxazole and trimethoprim is commonly used as treatment.

A case of African histoplasmosis from Sudan.

The first authentic case of African histoplasmosis from the Sudan is reported. The patient came from Dindir, along the southern part of the Blue Nile River. He had cutaneous and visceral leishmaniasis as well as the cutaneous form of African histoplasmosis. The latter was proved by culture and histopathology to be due to Histoplasma duboisii. The fungus was confined to the skin. H. duboisii may be more prevalent, and further studies in Dindir area are needed.

Humoral immune responses to mycetoma organisms: characterization of specific antibodies by the use of enzyme-linked immunosorbent assay and immunoblotting.

Levels of antibodies were determined by enzyme-linked immunosorbent assay (ELISA) in 13 patients with eumycetomas due to Madurella mycetomatis infections. Raised levels of specific IgM were observed in 12 patients, compared with normal human controls. By contrast, low levels of specific IgG were detected in some patients. Specific responses to separated protein antigens were investigated by immunoblotting. Of 10 patients' sera tested, IgM in 2 recognized up to 7 of the blotted antigens between 45 and 84 kDa. Gold-labelled protein A (which predominantly binds to IgG) indicated that sera from 2 patients reacted with at least 6 protein bands with relative molecular masses between 64 and 95. The demonstration of significant IgM levels by ELISA, but few antigenic bands in sera from the same patients by immunoblotting, may point to an antibody response against polysaccharide fungal antigens in mycetoma patients. The use of the ELISA to detect antibodies of different classes and the characterization of their antigenic specificities by immunoblotting may have both diagnostic and prognostic value.

The ultrastructure of actinomycetoma grains caused by Streptomyces somaliensis.

This study compares the in vitro ultrastructure of Streptomyces somaliensis with the grain formation seen in vivo. Cultured forms were cocco-bacillary with thick cell walls and septa. Individual cells stained with PAS.TCH and Alcian blue. Grains were largely composed of an electron-dense fibrillar matrix surrounding clear areas, some of which contained organisms. The ultrastructural appearances of the latter were not significantly different from those seen in vitro although the cell wall was less well defined and did not stain with Alcian blue, and there were more intracellular lipid droplets. Host cells surrounding the mass were incorporated into the structure of the grain, a process associated with cell death. The grains of S. somaliensis appear to be derived from both host and actinomycete elements. Compared to other mycetoma agents the mechanism of grain formation by this organism is distinctive.

Actinomycetoma of the mandibular region causing ankylosis.

A case of mycetoma of the mandibular region caused by Actinomadura madurae is presented. Diagnostic procedures and rationale for treatment are discussed. In tropical and subtropical areas where mycetoma is endemic it should be included in the differential diagnosis of tumours of the facio-maxillary region.

Ultrastructural and immunogenic changes in the formation of mycetoma grains.

The differences in the fine structure and antigenic determinants of mycetoma fungi in the mycelial phase in vitro and in grains in vivo facilitate an interpretation of grain formation. Aggregates of hyphal elements with multiple and thickened walls was a feature of the fungi in vivo. Associated with hyphal wall material, numerous polysaccharide microfibrils were detected in grains of Madurella mycetomatis. These were not seen associated with hyphal elements in vitro and it is suggested that these structures may be concerned with the aggregation of fungal elements in the formation of grains. Antibodies directed against the fungi in vitro were shown, by indirect immunogold labelling, to bind at identical sites in fungal material grown in vitro as in mycetoma grains. However the grain matrix was not labelled, suggesting that part of the structure formed in vivo is composed of modified antigen or is host derived.

Mycetoma of the head and neck.

Cranial mycetoma is not as rare as was believed. In the Sudan, the majority of cases are caused by S. somaliensis; no cases were found to be caused by Nocardia species. Cranial actinomycetoma proved to be potentially fatal and was the most difficult to treat. The best treatment results were achieved in cases of A. madurae infection.

Ketoconazole in the treatment of eumycetoma due to Madurella mycetomii.

Eumycetoma is, at present, treated only by surgery which is amputation at times and mutilating excision at others. Surgical treatment is often followed by local, or rarely distant recurrence to regional lymph nodes and surrounding tissue. The results of the clinical trial with ketoconazole reported in this paper show that five of 13 patients were completely cured and four improved. It is worth noting that the daily dose for those cured was 400 or 300 mg while those who improved were on only 200 mg/day.

Torulopsis glabrata and Candida albicans in female genital infections in the Sudan.

Four hundred and seventy Sudanese women with vaginal discharge were investigated for yeast-like fungi. High vaginal specimens were cultured and isolates fully identified according to standard mycological techniques. All patients were married and some were pregnant. Of 138 yeast-like fungi identified, Torulopsis glabrata (34.1%) was the commonest followed by Candida albicans (25.4%) and Candid krusei (14.5%). Differing social and economic factors may be responsible for the higher prevalence of T glabrata in the Sudan. Although its pathogenicity is not well established, its association with vulvovaginitis should not be overlooked.

Mycetomas in goats.

Naturally occurring mycetomas were found in 3 goats. Two had mycetomas on their hind legs and the third on its left scapula. In 2 goats the causative agents were identified by culture, histopathology and serology as Actinomadura madurae. In the remaining goat diagnosis was based only on histopathology and the causative agent was considered to be A. pelletierii. Despite minor differences between goat and human strains of A. madurae, it would seem that goats could be useful experimental models.