Fungal Infections in the Caribbean: A Review of the Literature to Date.

The most common fungal infections reported from the Caribbean include dermatophytosis, candidiasis, pneumocystis, aspergillosis, histoplasmosis, and cryptococcosis. The Caribbean is hyperendemic for histoplasmosis, with high population exposures. Fungal infections are a significant public health problem in the Caribbean, with rates varying depending on the specific country or region. In Trinidad and Tobago, the fungal burden accounts for 3.3% of the 1.4 million population, while in Jamaica, with a population of 2.9 million, over 57,600 people suffer from fungal infections each year. A study in the Dominican Republic estimated that approximately 221,027 (2%) of over 10 million people have a serious fungal infection. Fungal infections accounts for 21.9% of all skin infections in Haiti. The diagnosis of fungal infections in the Caribbean can be challenging, as access to laboratory testing and specialized medical services is limited in many areas. Access to antifungal medications can also be a challenge in some areas, and antifungal resistance has been reported.

Assessing Freshwater Microbiomes from Different Storage Sources in the Caribbean Using DNA Metabarcoding.

Next-generation sequencing (NGS) and the technique of DNA metabarcoding have provided more efficient and comprehensive options for testing water quality compared to traditional methods. Recent studies have shown the efficacy of DNA metabarcoding in characterizing the bacterial microbiomes of varied sources of drinking water, including rivers, reservoirs, wells, tanks, and lakes. We asked whether DNA metabarcoding could be used to characterize the microbiome of different private sources of stored freshwater on the Caribbean Island nation of Antigua and Barbuda. Two replicate water samples were obtained from three different private residential sources in Antigua: a well, an above-ground tank, and a cistern. The bacterial microbiomes of different freshwater sources were assessed using 16S rRNA metabarcoding. We measured both alpha diversity (species diversity within a sample) and beta diversity (species diversity across samples) and conducted a taxonomic analysis. We also looked for the presence of potentially pathogenic species. Major differences were found in the microbiome composition and relative abundances depending on the water source. A lower alpha diversity was observed in the cistern sample compared to the others, and distinct differences in the microbiome composition and relative abundance were noted between the samples. Notably, pathogenic species, or genera known to harbor such species, were detected in all the samples. We conclude that DNA metabarcoding can provide an effective and comprehensive assessment of drinking water quality and has the potential to identify pathogenic species overlooked using traditional methods. This method also shows promise for tracing the source of disease outbreaks due to waterborne microorganisms. This is the first study from small island countries in the Caribbean where metabarcoding has been applied for assessing freshwater water quality.

Transforming Medical Education: Assessing the Integration of ChatGPT Into Faculty Workflows at a Caribbean Medical School.

INTRODUCTION: ChatGPT is a Large Language Model (LLM) which allows for natural language processing and interactions with users in a conversational style. Since its release in 2022, it has had a significant impact in many occupational fields, including medical education. We sought to gain insight into the extent and type of usage of ChatGPT at a Caribbean medical school, the American University of Antigua College of Medicine (AUA). METHODS: We administered a questionnaire to 87 full-time faculty at the school via email. We quantified and made graphical representations of the results via Qualtrics Experience Management software (QualtricsXM, Qualtrics, Provo, UT). Survey results were investigated using bar graph comparisons of absolute numbers and percentages for various categories related to ChatGPT usage, and descriptive statistics for Likert scale questions. RESULTS: We found an estimated 33% of faculty were currently using ChatGPT. There was broad acceptance of the program by those who were using it and most believed it should be an option for students. The primary task ChatGPT was being used for was multiple choice question (MCQ) generation. The primary concern faculty had was incorrect information being included in ChatGPT output. CONCLUSION: ChatGPT has been quickly adopted by a subset of the college faculty, demonstrating its growing acceptance. Given the level of approval expressed about the program, we believe ChatGPT will continue to form an important and expanding part of faculty workflows at AUA and in medical education in general.

Cervical Cancer and Human Papillomavirus Awareness among Women in Antigua and Barbuda.

Background and objectives: Cervical cancer is the fourth leading cause of cancer-related deaths in women. Human papilloma virus (HPV) is known to cause cervical cancer. The incidence and mortality of cervical cancer has drastically reduced due to effective vaccination against HPV in developed countries. The projected rise in cervical cancer cases in Latin American and Caribbean countries necessitates a study to evaluate awareness about HPV, cervical cancer, the HPV vaccine, and prevention among women in Antigua and Barbuda. Materials and methods: This was an observational, cross-sectional study. The participants were women aged between 18 and 65 years, residing in Antigua and Barbuda. The study was conducted over the period of February to April 2023. After taking informed consent electronically, sociodemographic and behavioral data was collected through questionnaires sent out as links and QR-codes and were analyzed by QualtricsXM. The association between the demographic groups and awareness about HPV, cervical cancer, the HPV vaccine, and prevention was analyzed by a Chi-square test. Results: In total, 467 women were included in the study. The percentage of participants aware of HPV was 91.6% (n = 412). A total of 70.7% (n = 318) and 56.7% (n = 255) women were aware that cervical cancer is caused by HPV and is sexually transmitted, respectively. Although 70.6% (n = 315) of participants were aware that the vaccine protects against HPV, only 12.8% (n = 57) were vaccinated. Of the participants, 49.7% (n = 192) were willing to get vaccinated. The percentage of participants aware of the Papanicolaou (Pap) smear procedure was 98.9% (n = 435) and 87.8% (n = 382) had a Pap smear within the last 10 years while 12.2% (n = 53) never had a Pap smear screening. The willingness to know more information about HPV and the HPV vaccine among the participants was 77% (n = 335). Conclusions: The overall awareness among women in Antigua and Barbuda about HPV, cervical cancer, the HPV vaccine, and prevention was high. We recommend a national health education program and vaccine drive to complement our findings.

The Association of Microbiome Dysbiosis With Colorectal Cancer.

Many studies have been conducted to identify the causative organisms in colorectal cancer (CRC) and compare the microbiota of healthy individuals and those with CRC. The pathways by which the microbiota promotes CRC development are not yet fully understood. The hypothesized mechanisms include damage to the DNA, production of carcinogenic metabolites, and promotion of chronic inflammation. In a state of dysbiosis, the gut loses protective bacteria and is enriched with pathogenic and cancer-promoting bacteria, which promotes functions associated with cancer such as angiogenesis, loss of apoptosis, and cell proliferation. We have established a strong link between microbiota dysbiosis and certain species of bacteria and even viruses involved in tumorigenesis. In this review, we look at some of the major identified species and how they are related to CRC. Future research should include and even focus on mycobiome and virome on CRC development. Due to the diversity of the gut microbiome, there is a high possibility that the gain and loss of bacteria and their metabolic functions lead to CRC.

Trichosporon asahii infection associated with glomerulonephritis in a diabetic patient.

Trichosporon colonizes the skin, vagina, gastrointestinal and respiratory tract of humans. Superficial infections are common, while disseminated trichosporonosis is rare, specifically seen among immunocompromised patients and often associated with high mortality. We report a rare case Trichosporon asahii infection in a 78-year-old diabetic, with associated acute interstitial glomerulonephritis. Molecular identification of the isolate was confirmed by sequencing IGS1 region of rDNA. Our study adds to a rather limited literature on renal complications of Trichosporonosis.

Sociodemographic characteristics and spectrum of Malassezia species in individuals with and without seborrhoeic dermatitis/dandruff: A comparison of residents of the urban and rural populations.

Seborrhoeic dermatitis/dandruff (SD/D) is a common, persistent, relapsing inflammatory condition affecting the areas rich in sebaceous glands. SD/D is widely prevalent in India but Malassezia species implicated are not well studied. To estimate the prevalence and spectrum of Malassezia species causing SD/D and understand the sociodemographic characteristics of SD/D in rural and urban populations, a total of 200 SD/D patients and 100 healthy controls (HC) from both rural and urban backgrounds were enrolled in this study. SD/D severity was clinically graded as mild, moderate, severe, and very severe. The isolates were identified by phenotypic characters and confirmed by ITS2 PCR-RFLP and sequencing of the ITS region of rDNA. Severe (59%) and very severe (71%) form of SD/D was higher in the rural population compared to the urban population (P = .004). The isolation rate of Malassezia was significantly higher in overall SD/D patients scalp (82%) compared to HC (67%) (P = .005). From the scalp of SD/D patients, M. globosa (36.2%) was predominantly isolated followed by M. restricta (31.3%), M. furfur (15.7%), a mixture of M. globosa and M. restricta (12%) or M. arunalokei (4.8%). Similarly, M. globosa (49.3%) was predominately isolated from the scalp of HC followed by M. restricta (22.4%). M. restricta was significantly higher in the scalp of SD/D patients compared to HC and/or nasolabial fold of both SD/D patients and HC (P = .0001). Our findings indicate that M. restricta has a high association with SD/D. More severe disease frequency was observed in the rural population. PRECIS: Dandruff is associated with Malassezia restricta and very severe cases are higher in rural population, probably due the poor hygiene. Moderate to severe hair loss and itching were strongly associated with dandruff. Use of soaps to cleanse scalp appears to be better than shampoo in preventing dandruff.

Molecular Identification and Quantification of Malassezia Species Isolated from Pityriasis Versicolor.

BACKGROUND: Pityriasis versicolor (PV) is the most common chronic superficial infection of the stratum corneum, reported in 40-60% of the tropical population. After the description of the new Malassezia species, only a few studies have been conducted from India. AIMS: Molecular identification, quantification of Malassezia species implicated with PV and correlation to its clinical presentation. MATERIALS AND METHODS: The subjects include 50 PV patients, who attended the dermatology outpatient department of our hospital and 50 healthy individuals. Same size area of the skin was sampled from lesional and non-lesional sites in the patient group and from forehead, cheek, and chest of healthy individuals. Malassezia spp. isolated were identified by conventional method and confirmed by ITS2 PCR-RFLP and sequencing of D1/D2 region of 26S rDNA. RESULTS: Eighty percent of patients presented with hypopigmented lesions and 20% with hyperpigmented lesions. From PV lesions, the most frequently isolated species was M. furfur (50%), followed by M. globosa (27.3%), mixture of M. furfur and M. globosa (15.9%), M. sympodialis (4.5%), and M. slooffiae (2.3%). Higher Malassezia density was found in lesional area as compared to non-lesional area of PV patients and in healthy individuals (P 0.0001). CONCLUSION: Although M. furfur was the most prevalent species isolated from both patients and controls, significantly higher isolation of M. globosa from the lesional area compared to non-lesional area indicates its possible role along with M. furfur in causing PV.

Vitamin C: A Preventative, Therapeutic Agent Against Helicobacter pylori.

The treatment of Helicobacter pylori (H. pylori) induced infections using antibiotic therapies is clinically well accepted; however, using a noninvasive approach with the implementation of therapeutic agents such as vitamin C is not well investigated. Vitamin C has certain characteristics, which allow for it to be considered as a potential treatment option for patients with H. pylori infections. Vitamin C's hostility and mechanism of action towards H. pylori infection in peptic ulcer disease can be classified into two categories: as a preventative agent and alternatively as a therapeutic agent. Preventatively vitamin C acts as a biological antioxidant as well as an immune boosting agent, while therapeutically it acts as an inhibitor of urease, a potential collagen synthesizing agent, and a stimulant in prostaglandin synthesis. As a result, the dosage of vitamin C should be highly regulated. Furthermore, numerous studies have shown that vitamin C supplementation if taken with antibiotics can increase the efficiency of the treatment leading to an increased possibility of eradication of H. pylori in infected individuals. This paper will investigate the recent studies that show different mechanisms through which vitamin C can be used as a preventative or a therapeutic agent for the treatment of H. pylori related infections.

Molecular diagnosis of rhino-orbito-cerebral mucormycosis from fresh tissue samples.

PURPOSE: We aimed to evaluate a PCR-based technique for the diagnosis of mucormycosis and the identification of fungi from fresh tissue specimens in patients with rhino-orbito-cerebral-mucormycosis (ROCM). METHODOLOGY: Fifty cases of ROCM were included in the study. Conventional identification was performed using microscopy and culture. Molecular diagnosis was performed by amplifying the ribosomal DNA using pan-fungal ITS primers and semi-nested Mucorales-specific primers of the 18S region. The amplified products were sequenced to identify the agents. The utility of PCR-RFLP of the 18S region of rDNA was evaluated to identify the Mucorales. RESULTS: The ROCM cases were diagnosed by the demonstration of aseptate ribbon-like hyphae in biopsy specimens collected from the patients. Isolation was possible in 24 (48 %) samples. The ITS2 PCR confirmed mucormycosis in 27 cases (54 %; CI 59.4-68.2). By comparison, Mucorales-specific PCR was able to amplify DNA and the sequence enabled the identification of Mucorales speciesin all the patients. PCR-RFLP of the 18S region of rDNA could only identify the agent to genus level. CONCLUSION: The molecular technique was able to identify Mucorales species in 26 (42 %) cases that were negative by culture. Mucorales-specific semi-nested PCR targeting the 18S region is a better technique than ITS2 PCR for diagnosis. PCR-RFLP of the 18S region helps in identification to genus level.

ß-Endorphin enhances the phospholipase activity of the dandruff causing fungi Malassezia globosa and Malassezia restricta.

ß-Endorphin is known to stimulate phospholipase production by Malassezia pachydermatis during canine dermatoses. The role of ß-endorphin in Malassezia infection in humans is not well studied. The present study compares the influence of ß-endorphin on Malassezia globosa and Malassezia restricta isolated from patients with seborrhoeic dermatitis/dandruff (SD/D) and healthy controls. Malassezia isolates (five each of the two species from patients and healthy controls) were grown on modified Dixon's agar with or without 100 nmol/L ß-endorphin. Phospholipase activity was quantified based on its ability to hydrolyze L-α-phosphatidylcholine dimyristoyl (phospholipid substrate). Free fatty acid was measured by a colorimetry method. In isolates from patients, the phospholipase activity significantly increased after exposure to ß-endorphin (M. globosa, P = .04; M. restricta, P = .001), which did not occur in isolates from healthy controls. Moreover, after ß-endorphin exposure the patient isolates had significantly higher (P = .0004) phospholipase activity compared to the healthy control isolates. The results suggest that isolates of M. globosa and M. restricta from patients may differ from those of healthy humans.

Malassezia arunalokei sp. nov., a Novel Yeast Species Isolated from Seborrheic Dermatitis Patients and Healthy Individuals from India.

The majority of species within the genus Malassezia are lipophilic yeasts that colonize the skin of warm-blooded animals. Two species, Malassezia globosa and Malassezia restricta, are implicated in the causation of seborrheic dermatitis/dandruff (SD/D). During our survey of SD/D cases, we isolated several species of Malassezia and noticed vast variations within a few lipid-dependent species. Variations observed in the phenotypic characteristics (colony morphology, absence of catalase activity, growth at 37°C, and precipitation surrounding wells containing Tween 20 or Cremophor EL) suggested the possible presence of a novel species. Sequence divergence observed in the internal transcribed spacer (ITS) region, the D1/D2 domain, and the intergenic spacer 1 (IGS1) region of rDNA and the TEF1 gene, PCR-restriction fragment length polymorphism (RFLP) analysis of the ITS2 region, and fluorescent amplified fragment length polymorphism analysis support the existence of a novel species. Based on phenotypic and molecular characterization of these strains, we propose a new species, namely, M. arunalokei sp. nov., and we designate NCCPF 127130 (= MTCC 12054 = CBS 13387) as the type strain.

Molecular characterisation and antifungal susceptibility of clinical Trichosporon isolates in India.

In Asian countries, Trichosporon infection is a well-known disease in Japan. In India, the infection is increasingly recognised. The study was conducted to characterise the clinical Trichosporon isolates from India by phenotypic and molecular techniques. A total of 31 Trichosporon clinical isolates, recovered from patients of 14 hospitals across India were sequenced (ITS and IGS1 regions of rDNA). In vitro drug susceptibility testing of the isolates was performed against amphotericin-B, fluconazole, itraconazole, voriconazole and posaconazole. IGS1, rather than ITS sequences, correctly identified the isolates: Trichosporon asahii, 20; Trichosporon ovoides, 3; Trichosporon inkin, 2; Trichosporon asteroides, 1; Trichosporon mucoides, 1; Trichosporon loubieri, 1; Trichosporon debeurmannianum, 1; and Trichosporon dermatis, 1. Trichosporon asahii genotype III was the most common type, followed by genotype I and VII. Both these targets did not help to identify one Trichosporon to the species level. Trichosporon debeurmannianum, T. dermatis and T. asteroides were isolated for the first time from a human disease in India. The minimum inhibitory concentrations for voriconazole and posaconazole were within effective range. The study highlights the presence of wide range of Trichosporon species causing infection in India. Voriconazole or posaconazole may be the better drugs to treat such patients.

Emergence of Magnusiomyces capitatus infections in Western Nepal.

Magnusiomyces capitatus is an emerging opportunistic yeast in the Mediterranean region. We report from Nepal one case of M. capitatus infection and six other cases of colonization/probable infection due to M. capitatus at a tertiary care center. Majority of the patients were immunocompromised, at extreme age, associated with comorbidities, and had history of close contact with livestock and poultry. The isolates were identified by phenotypic and genotypic (ITS and D1/D2 region of 26S rDNA sequence) methods. Molecular typing of the isolates was carried out by amplified fragment length polymorphism. Minimum inhibitory concentration (MIC) of the isolates for amphotericin B, caspofungin, fluconazole, itraconazole, voriconazole, posaconazole, anidulafungin, and micafungin were 2, 0.1-4, 2, 0.12-0.5, 0.12-0.5, 0.25, 1-4, and 1-4 µg/ml, respectively. Presence of M. capitatus infection was not known in Nepal, and the study should alert the clinicians and infectious disease specialists.

Disseminated Emmonsia pasteuriana infection in India: a case report and a review.

We report here the first case of disseminated Emmonsia pasteuriana infection in a patient with AIDS in India. The patient presented with weight loss, dyspnoea, left-sided chest pain and multiple non-tender skin lesions over face and body for 3 months. Disseminated emmonsiosis was diagnosed on microscopic examination and fungal culture of skin biopsy and needle aspirate of lung consolidation. It was confirmed by sequencing internal transcribed spacer region of rDNA, beta tubulin, actin, and intein PRP8. The patient responded to amphotericin B and itraconazole therapy.

Invasive pulmonary mycosis due to Chaetomium globosum with false-positive galactomannan test: a case report and literature review.

In this case, the authors report Chaetomium globosum as a cause of invasive pulmonary infection in a patient with Wegener's granulomatosis. Fungal hyphae (KOH and Calcofluor) were seen on direct microscopy of lung biopsy sample and bronchoalveolar lavage (BAL) sample. C. globosum isolated on culture clinched the diagnosis of invasive pulmonary infection by Chaetomium spp. A positive galactomannan of serum and BAL was repeatedly seen and was utilised for follow-up and as prognostic marker in patient management. The patient was successfully treated with liposomal amphotericin B followed by voriconazole. All the Chaetomium infections reported till date since 1980 are reviewed. Chaetomium spp. with its unique ecology has a hidden clinical potential to cause invasive mould infections.

Molecular identification of clinical Nocardia isolates from India.

The epidemiology of nocardiosis is evolving with increasing number of Nocardia spp. causing human infection. In recent years, molecular techniques have been used to identify Nocardia spp. There are limited data available on the spectrum of Nocardia spp. isolated from clinical samples in India. Here, a molecular study was carried on 30 clinical isolates maintained in our National Culture Collection to evaluate the techniques used for identifying the agents. The isolates were identified by sequencing two promising genes: the 16S rRNA gene and hsp65. Both hsp65 and the 16S rRNA gene could reliably identify 90 % of Nocardia isolates, i.e. N. farcinica, N. cyriacigeorgica, N. brasiliensis, N. otitidiscaviarum, N. amamiensis and N. pneumoniae. The mean percentage dissimilarity of sequence identification was higher using the hsp65 gene (4 %, range 0-7.9 %) compared with the 16S rRNA gene (2.3 %, range 0-8.9 %). Two isolates that showed ambiguous results in both the short segment of the 16S rRNA gene and hsp65 sequences could be resolved by sequencing a larger fragment (∼1000 bp) of the 16S rRNA gene. Both of these isolates were identified as N. beijingensis with similarities of 99.8 and 100 % compared with the standard strain. Genotyping of N. cyriacigeorgica strains was performed using hsp65 gene sequences and compared with previously described genotypes. Our N. cyriacigeorgica isolates belonged to genotype 1 (n = 4) and genotype 2 (n = 2). The present study highlights a wide spectrum of Nocardia spp. in India and emphasizes the need for molecular techniques for identification to the species level.

Phenotypic and molecular characterization of Malassezia japonica isolated from psoriasis vulgaris patients.

Malassezia species, which are skin colonizers, are being debated as to their pathogenic role in various cutaneous diseases. Species identification of Malassezia is important as particular species have been implicated in or associated with specific diseases. Malassezia japonica, a relatively newly described species, has not been completely characterized owing to the rarity of its isolation. In the present study we describe phenotypic and molecular characterization of six M. japonica strains isolated from patients with psoriasis vulgaris. In contrast to the physiological and biochemical properties of the M. japonica type strain, CBS9348, all our isolates assimilated Tween 20 and showed positive ß-glucosidase activity, and the Cremophor EL utilization test was negative. However, the sequences of the D1/D2 region of rDNA, ITS2 and IGS1 regions of all our isolates clustered with the type strain of M. japonica.

Skin Colonization by Malassezia spp. in hospitalized neonates and infants in a tertiary care centre in North India.

Malassezia, a skin colonizer, is associated with multiple skin disorders in adults, and cephalic pustulosis and folliculitis in children. It can cause fungemia in infants and neonates. The time and pattern of colonization, risk factors associated with colonization and causing fungemia in children, are not well understood. The prospective cohort study was conducted to determine the rate of Malassezia species colonization and associated factors in hospitalized neonates and infants. Consecutive 50 neonates and infants admitted in neonatal and pediatric intensive care units were studied. The skin swabs were collected on the day of admission and every fifth day, thereafter, till the patient was discharged or died. Putative risk factors for the colonization of Malassezia species were recorded. Isolates were identified by phenotypic methods and sequencing of the D1 and D2 region of rDNA. Neonates were not colonized at the time of entry in neonatal ICU or at birth. Nineteen (38 %) neonates were colonized with Malassezia species during their hospital stay. Among the infants, three (6 %) came to ICU with Malassezia colonization and 26 (52 %) acquired Malassezia during ICU stay. Mechanical ventilation, duration of hospital stay, central venous catheterization, and antifungal therapy were the significantly associated factors for colonization. Malassezia furfur was the most common species isolated from the skin of infants and neonates. Colonization by Malassezia species in infants and neonates in a hospital is not uncommon and can be a potential source of nosocomial infection.

Association of Malassezia species with dandruff.

BACKGROUND & OBJECTIVES: Malassezia species implicated with dandruff vary at different geographical locations. The present study was conducted to determine the spectrum and distribution of Malassezia species in dandruff patients and healthy individuals. METHODS: Patients with dandruff from northern (Chandigarh) and southern (Manipal, Karnataka) parts of India (50 each) and healthy individuals (20) were included in the study. Dandruff severity was graded as mild, moderate and severe. Malassezia spp. isolated were quantified and identified by phenotypic characters and molecular methods including PCR-RFLP and DNA sequencing. RESULTS: Number of Malassezia spp. retrieved was significantly higher (P<0.001) in dandruff cases (84%) as compared to healthy individuals (30%). Isolation of Malassezia spp. was significantly higher (P<0.01) in patients from southern India. In moderately severe cases M. restricta was single most predominant (37.8%) isolate from patients of northern part of India and M. furfur (46.4%) from patients of southern part of India. Malassezia density was significantly associated with the severity of dandruff (P<0.001). INTERPRETATION & CONCLUSIONS: Our results on a limited number of individuals show that Malassezia spp. associated with dandruff varies in different regions of the country and the density of yeasts increases with severity of disease.