Azole Resistance and cyp51A Mutation of Aspergillus fumigatus in a Tertiary Referral Hospital in Taiwan.

Azole resistance in Aspergillus fumigatus has increasingly been reported worldwide. Its major mechanism of resistance is mediated by mutations in cyp51A. The objective of this study was to test the antifungal susceptibilities of A. fumigatus isolates from Chang Gung Memorial Hospital (CGMH), the largest tertiary referral hospital in Taiwan, and to investigate cyp51A mutations in azole-resistant strains. A. fumigatus isolates preserved in the Research Laboratory of Medical Mycology of CGMH from 2015 to 2021 were used. Antifungal susceptibility testing was performed using the YeastOneTM method. Isolates with high minimal inhibitory concentrations (MICs) against antifungals were further tested using the Clinical and Laboratory Standards Institute (CLSI) broth microdilution method. Mutations in the cyp51A in azole-resistant strains were detected by Sanger sequencing. The overall prevalence of azole-resistant isolates was 1.77% (two out of 113 isolates). The two azole-resistant strains had tandem repeats (TR) in the promoter region and mutations in the cyp51A gene (TR34/L98H and TR34/L98H/S297T/F495I). One strain showed intermediate susceptibility to voriconazole, and its Cyp51A protein had five amino acid substitutions (F46Y/M172V/N248T/D255E/E427K). TR34/L98H and TR34/L98H/S297T/F495I are the most prevalent cyp51A mutations in Taiwan, mediating azole resistance based on current publications and our results. YeastOneTM was validated as a rapid tool for the antifungal susceptibility test; however, further confirmation by CLSI should be considered when MIC values of voriconazole, posaconazole, and amphotericin B are close to the clinical breakpoints or ecological cutoff values.

Disseminated intravascular coagulation in Stevens-Johnson syndrome and toxic epidermal necrolysis.

BACKGROUND: Patients with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) have high mortality rates. Disseminated intravascular coagulation has been reported in SJS/TEN patients. The influence of this lethal complication in patients with SJS/TEN is not well known. OBJECTIVE: This study aimed to investigate the risk and outcomes of disseminated intravascular coagulation in patients with SJS/TEN. METHODS: We analyzed the disseminated intravascular coagulation profiles of patients receiving a diagnosis of SJS/TEN between 2010 and 2019. RESULTS: We analyzed 150 patients with SJS/TEN (75 with SJS, 22 with overlapping SJS/TEN, and 53 with TEN) and their complete disseminated intravascular coagulation profiles. Disseminated intravascular coagulation was diagnosed in 32 patients (21.3%), primarily those with TEN. It was significantly associated with systemic complications, including gastrointestinal bleeding, respiratory failure, renal failure, liver failure, infection, and bacteremia. Additionally, SJS/TEN patients with disseminated intravascular coagulation had elevated procalcitonin levels. Among patients with SJS/TEN, disseminated intravascular coagulation was associated with a greater than 10-fold increase in mortality (78.1% vs 7%). LIMITATIONS: The study limitations include small sample size and a single hospital system. CONCLUSION: Disseminated intravascular coagulation is a potential complication of SJS/TEN and associated with higher mortality. Early recognition and appropriate management of this critical complication are important for patients with SJS/TEN.

Novel three-dimensional image system for endoscopic ear surgery.

OBJECTIVE: The objective of this study was to evaluate the clinical outcomes of conventional two-dimensional (2D) endoscope with a novel computer-based three-dimensional (3D) imaging system for otologic surgical procedures. METHODS: A conventional 2D monocular endoscope with a novel computer-based 3D imaging system was applied to 18 otologic surgical procedures, including chronic otitis media (COM), cholesteatoma, otosclerosis, external canal osteoma and cochlear implant. Operation duration and complications of COM and attic cholesteatoma were recorded to compare 2D and 3D endoscopic ear surgery. Questionnaires were completed by 35 observers participating in the procedures and were used to evaluate clinical and potential side effects. RESULTS: The surgical procedures were performed smoothly for all patients. No patient required switching to conventional 2D endoscopic surgery. No significant differences were apparent in operation duration using the 3D imaging system for chronic otitis media and attic cholesteatoma compared with conventional 2D endoscopic ear surgery. Thirty-five observers completed the questionnaires. Most of them agreed that this 3D imaging system enabled them to perceive stereoscopic vision (94%), provide superior depth perception (85%). Furthermore, 97.1% reported no visual fatigue or discomfort when observing the 3D images. CONCLUSION: Our study demonstrated that the computer-based 3D imaging system enables the application of 3D vision technology to otologic surgery. The system has no obvious side effects, such as visual fatigue or time delay. It not only facilitates performing the related surgical procedures but also helps in teaching and learning endoscopic ear surgeries.