Prospective study in critically ill non-neutropenic patients: diagnostic potential of (1,3)-ß-D-glucan assay and circulating galactomannan for the diagnosis of invasive fungal disease.

Diagnosis of invasive fungal disease (IFD) in patients under intensive care is challenging. Circulating biomarkers, (1,3)-ß-D-glucan (BG) and galactomannan (GM), were prospectively assessed in 98 critically ill patients at risk of IFD. There were 11 cases of invasive aspergillosis (IA; 4 proven and 7 probable), 9 cases of proven invasive candidiasis (IC), 1 case of mixed proven IC and probable IA, 1 case of proven zygomycosis, and 1 case of mixed mycelial proven IFD. In all IA cases there was no significant difference when the area under the receiver operating characteristic curve (AUC) of GM (0.873 [95%CI, 0.75-0.99]) and BG (0.856 [95% CI, 0.71-0.99]) were compared (p = 0.871). The AUC for BG in IC and for the rest of the IFD cases was 0.605 (95% CI, 0.39-0.82) and 0.768 (95% CI, 0.63-0.90) respectively. Positive BG (40%) predated blood culture (n = 3) and abdominal pus (n = 1) a mean of 3.25 days before Candida was grown. In patients with IFD caused by molds, BG appeared a mean of 5.65 days before culture results. For the diagnosis of patients at risk of IC, BG has shown a high NPV (94.5%), with positive results also predating blood cultures in 30% of patients. In conclusion, early BG results permit a timely initiation of antifungal therapy in patients at risk of IFD.

A prospective comparison of galactomannan in bronchoalveolar lavage fluid for the diagnosis of pulmonary invasive aspergillosis in medical patients under intensive care: comparison with the diagnostic performance of galactomannan and of (1→ 3)-ß-d-glucan chromogenic assay in serum samples.

Diagnosis of fungal pneumonia (FP) in critically ill patients is challenging. Circulating biomarkers for the diagnosis of FP have limitations and the combination of different assays in serum samples and directly from the target organ may further improve the diagnosis of FP. We prospectively assessed the diagnostic utility of paired galactomannan (GM) in bronchoalveolar lavage fluid (BAL) and serum GM and (1→3)-ß-D-glucan (BG) assays in critically ill patients at risk of FP. Patients with FP were classified according to European Organisation for Research and Treatment of Cancer-Mycoses Study Group criteria, with modifications. Out of 847 admissions, 51 patients were eligible. There were nine invasive aspergillosis (IA) cases (four proven, five probable), three proven Pneumocysitis jirovecii pneumonia (PJP) cases and one mixed FP case (probable IA and proven PJP). The diagnostic accuracy as given by the area under the receiver operating characteristic curve in IA cases (proven and probable) for GM in BAL was 0.98 (95% CI, 0.94-1.00), whilst for GM and BG in serum it was 0.85 (95% CI, 0.74-0.96) and 0.815 (95% CI, 0.66-0.96), respectively. For IA cases (proven and probable) AUC for GM in BAL was significantly higher than GM and BG in serum (p 0.025 and p 0.032, respectively). In one of four proven and one of six probable IA cases, GM in serum remained negative, whereas GM in BAL was positive. In patients with IA, GM (90%) and BG (80%) appeared a mean of 4.3 days (range, 1-10 days) before Aspergillus was cultured. GM detection in BAL appears to improve the diagnosis of IA in critical patients.

Clinical significance of the detection of Candida albicans germ tube-specific antibodies in critically ill patients.

The present study, comprising a prospective multicentre study including 53 non-neutropenic patients from intensive care units (ICU) in six Spanish tertiary-care hospitals, was carried out to determine the clinical significance and influence on mortality of Candida albicans germ tube-specific antibodies (CAGTA). There were 22 patients (41.5%) for whom the CAGTA results were positive, although none of had a blood culture positive for Candida. The intra-ICU mortality rate was significantly lower (p = 0.004) in CAGTA-positive patients (61.2% vs. 22.7%). Multivariate analysis confirmed that a positive CAGTA result was the only protective factor to be independently associated with ICU mortality (beta coefficient = -0.3856; 95% confidence interval = -0.648 to -0.123).

Whole Saliva has a Dual Role on the Adherence of Candida albicans to Polymethylmetacrylate.

Adhesion of Candida albicans to acrylic of dental prostheses or to salivary macromolecules adsorbed on their surface is believed to be a critical event in the development of denture stomatitis. In previous studies our group has shown that adhesion of C. albicans germ tubes to polystyrene is decreased by saliva whereas C. albicans yeast cells adhesion to the same material is enhanced. The results presented in this study confirm this dual role played by whole saliva, since it decreased the adhesion of germ tubes but increased the adhesion of yeast cells to polymethylmetacrylate (PMMA). These effects mediated by whole saliva do not seem to be related to an inhibition of the germination of C. albicans, since similar levels of filamentation were observed in presence and absence of saliva. These results may give new insights into the conflicting role of saliva in the adhesion of C. albicans to acrylic resins of dental prostheses.

Diagnostic potential of (1, 3)-beta-D-glucan and anti-Candida albicans germ tube antibodies for the diagnosis and therapeutic monitoring of invasive candidiasis in neutropenic adult patients

Se ha evaluado la utilidad de la detección dos veces por semana de Beta-glucano (BG) y de anticuerpos anti-micelio de Candida albicans (CAGT) para el diagnóstico y el seguimiento de la candidiasis invasora (CI) en 35 episodios de pacientes neutropénicos de alto riesgo. Se diagnosticaron tres casos de CI probada y tres probables. Se alcanzaron resultados positivos para ambos marcadores en el 100% de las CI probadas y en el 66% de las CI probables. La sensibilidad, especificidad, valores predictivos positivo y negativo para la detección de BG y anticuerpos contra CAGT fueron 83,3%, 89,&%, 62,5% y 96,3%, y 83,3%, 86,2%, 55,5% y 96,1%, respectivamente. El porcentaje de falsos positivos para BG y anticuerpos contra CAGT fue del 10,3% y 13,8% para la detección de BG y anticuerpos anti-CAGT, respectivamente. Sin embargo, los pacientes con resultados falsos positivos fueron diferentes para cada prueba. Ambas pruebas se anticiparon al diagnóstico clínico y radiológico, así como al inicio de la terapia antifúngica en la mayoría de los pacientes. La combinación de ambas pruebas mejoró la especificidad y el valor positivo hasta el 100%(AU)

The usefulness to diagnose and monitor invasive candidiasis (IC) using beta-glucan (BG) and antibodies against Candida albicans germ tubes (CAGT) was evaluated in a twice-weekly screening of 35 episodes in neutropenic adults at high risk. Three proven IC and three probable IC were assessed. Diagnostic levels of both markers were detected in 100% of proven IC and in 66% of probable IC. Sensitivity, specificity, positive and negative predictive values of BG and anti-CAGT antibodies detection were 83.3%, 89.6%, 62.5% and 96.3%, and 83.3%, 86.2%, 55.5%, 96.1%, respectively. False positive reactions occurred at a rate of 10.3% and 13.8% for the detection of BG and anti-CAGT antibodies, respectively. However, the patients with false positive results were different by each test. Both tests anticipated the clinical and radiological diagnosis, and the initiation of antifungal therapy in most patients. Combination of both tests improved specificity and positive predictive value to 100%(AU)

Isolation of Issatchenkia occidentalis from the esophagus of a leukemic patient

Se ha aislado Issatchenkia occidentales de una biopsia de esófago de un joven con leucemia. El paciente presentaba lesiones esofágicas herpéticas un mes después de recibir un trasplante de médula ósea. La identificación del aislamiento no se pudo realizar por los métodos comerciales existentes, por lo que se recurrió a la secuenciación de un fragmento de DNA amplificado por PCR utilizando cebadores panfúngicos(AU)

Issatchenkia occidentalis was isolated from an esophageal biopsy of a young leukemic male patient who underwent bone marrow transplantation. At the time the specimen was collected, the patient was also suffering from esophageal herpetic lesions. The identification of the isolate was not possible by the use of the available(AU)commercial methods. Thus, its identification was done by PCR and DNA sequencing using panfungal primers(AU)

In vitro activities of voriconazole and five licensed antifungal agents against Candida dubliniensis: comparison of CLSI M27-A2, Sensititre YeastOne, disk diffusion, and Etest methods.

We compared the in vitro activity of six antifungal agents against 62 isolates of Candida dubliniensis by the Clinical Laboratory Standards Institute (CLSI [formerly National Committee for the Clinical Laboratory Standards]) M27-A2, Sensititre YeastOne, disk diffusion, and Etest methods and we studied the effect of the time of reading. For the azoles, voriconazole was the most potent in vitro followed by fluconazole, ketoconazole, and itraconazole. All the isolates were susceptible to amphotericin B and flucytosine. The highest rate of resistance was obtained against itraconazole with a high number of isolates defined as susceptible dose-dependent. At 24 hr, 100% of the isolates were susceptible to ketoconazole, amphotericin B, and flucytosine, 98% susceptible to voriconazole and fluconazole, and 95% for itraconazole. At 48 hr, 100% of the isolates remained susceptible for flucytosine and amphotericin B, 95% for voriconazole, 93% for fluconazole, 90% for ketoconazole, and 82% for itraconazole. The agreement between the CLSI and the other methods was better at 24 than 48 hr.

Antifungal and antitumor activities of a monoclonal antibody directed against a stress mannoprotein of Candida albicans.

Immunization of mice with a stress mannoprotein of >200 kDa from the cell wall of Candida albicans led to the production of monoclonal antibody (Mab) C7. The immunogen is a major target of secretory IgA and its expression is regulated by different environmental conditions including temperature, pH, glucose concentration and ammonium sulphate in the culture medium. Mab C7 reacted with a peptide epitope present in the >200 kDa antigen as well as in a number of antigens from the blastoconidium and germ tube cell wall, including enolase. In addition to its reactivity with C. albicans, Mab C7 also reacted with antigens present in C. krusei, C, tropicalis, C. glabrata, C. dubliniensis and C. lusitaniae, as well as in Cryptococcus neoformans, Scedosporium prolificans and Aspergillus fumigatus. Mab C7 exhibited four important biological activities, namely inhibition of adhesion of C. albicans to a variety of surfaces, inhibition of germination of C. albicans, direct candidacidal activity and direct tumoricidal activity. In tumor cells, Mab C7 reacted with nucleoporin Nup88, a reactivity that can be utilized for diagnostic and prognostic purposes.

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.

Inhibition of adherence of Candida albicans and Candida dubliniensis to a resin composite restorative dental material by salivary secretory IgA and monoclonal antibodies.

OBJECTIVE: The attachment of Candida to oral surfaces is a crucial step in the colonization of the oral cavity and the eventual development of oral diseases caused by this microorganism. Inhibition of adhesion is one of the strategies currently studied to prevent Candida infections. The main objective of this study was to investigate the inhibitory effect of the human salivary components on the adherence of Candida albicans and C. dubliniensis to Herculite, a widely used resin composite restorative dental material. We have also investigated the influence on the adherence of three monoclonal antibodies (mAbs) directed against C. albicans cell wall antigens. DESIGN: The adhesion of three strains of C. albicans and one strain of C. dubliniensis was studied by a visual method after incubating the fungus and the resin in presence and in absence of human whole saliva, secretory immunoglobulin A (sIgA) and three mAbs directed against C. albicans cell wall surface antigens. RESULTS: Adherence of C. albicans was inhibited by whole saliva (41.7%), salivary sIgA (55.7%) and the salivary components that bind to the cell wall (36.7%). Whole saliva significantly reduced the adhesion of C. dubliniensis to Herculite to 45.3% of the control level. Saliva previously adsorbed with fungal cells or sIgA depleted saliva had no effect on adherence. An inhibition in the adhesion of C. albicans and C. dubliniensis to Herculite similar to that shown by whole saliva was also observed when mAbs C7 and 26G7 were used. However, mAb 21E6 increased adhesion of all the strains to Herculite. CONCLUSIONS: The results suggest that sIgA, as well as whole saliva, are important in blocking adherence of C. albicans and C. dubliniensis to Herculite and that this effect can be reproduced with mAbs directed against the cell wall surface of C. albicans.

Performance of Bacticard Candida compared with the germ tube test for the presumptive identification of Candida albicans.

Bacticard Candida was compared with the germ tube test for the rapid, presumptive identification of Candida albicans. This test kit detects the enzymatic activities l-proline aminopeptidase and beta-galactosaminidase in yeast colonies grown on culture media. Candida albicans produces both enzymes whereas other yeasts produce only one or neither of the enzymes. We evaluated 536 isolates including eight genera and 33 species of medically important yeasts, including 228 C. albicans and 36 C. dubliniensis. Both tests did not discriminate between C. albicans and C. dubliniensis isolates. The sensitivity and specificity for the Bacticard Candida test were 97.8 and 96.5%, respectively. Bacticard Candida and germ tube tests detected 246 (93.2%), and 256 (97%) C. albicans plus C. dubliniensis isolates. There were eight false-positive results with BactiCard Candida kit and four false-positive results with the germ tube test. Positive and negative predictive values for Bacticard Candida enzymatic test were 95.3 and 98.4%, respectively, while 97.4 and 98.1% for the germ tube test, its specificity being 98.1% and efficiency 97% (97.7% for germ tube). We have observed slightly lower values of sensitivity and specificity than those reported by others using the BactiCard test kit. Bacticard Candida provides a rapid and accurate alternative to the germ tube test for the presumptive identification of C. albicans.

Gingivostomatitis after eating fish parasitized by Anisakis simplex: a case report.

Anisakis simplex (AS) is a nematode that may be encountered as a parasite in various kinds of seafood. Human beings may accidentally acquire AS larvae by eating raw or undercooked seafood. In addition to human parasitization (anisakiasis), this nematode can induce allergic reactions. AS-related diseases are frequent, especially in those countries with a high level of fish consumption and with traditions of eating raw or undercooked seafood. To our knowledge, this is the first report of gingivostomatitis secondary to the ingestion of fish with AS parasites.

Molecular typing of clinical and environmental isolates of Scedosporium prolificans by inter-simple-sequence-repeat polymerase chain reaction.

Invasive infections by Scedosporium prolificans have increased alarmingly in recent years, mainly in immunosuppressed patients. The epidemiology, pathogenesis and the natural habitat of this pathogen are practically unknown. Isolates of S. prolificans were distinguished from one another by inter-simple-sequence-repeat (ISSR) fingerprinting, a technique based on the high degree of polymorphism of the multisatellite genetic markers used. This technique was found useful for typing 84 isolates of S. prolificans from different countries and sources. The assemblage of S. prolificans isolates tested was extremely diverse, with 35 genotypes present. Several patients were found to have been infected or colonized by more than one strain. Overall, this technique facilitates the epidemiological study of S. prolificans infection.

Isolation and characterization of an avirulent Candida albicans yeast monomorphic mutant.

Mutagenesis of Candida albicans strain ATCC 26555 with N-methyl-nitro-N-nitrosoguanidine followed by plating on solid yeast nitrogen base-N-acetylglucosamine medium at 37 degrees C yielded colony morphology variants that were characterized as forming smooth colonies, in contrast to the rough colonies formed by the parental strain. One yeast monomorphic mutant, CAL4, was studied in detail. Strain CAL4 is defective in filamentous growth, unable to form hyphae or pseudohyphae in vivo and in vitro. These filamentous structures are not elicited by commonly used external stimuli such as serum. The mutant had no obvious alterations in its mannan, glucan or chitin content. The total quantity of non-covalently linked wall proteins was reduced in the mutant strain, but the electrophoretic pattern shown by these proteins was identical to that of proteins from the parental strain. CAL4 showed major differences from the parental strain in its formation of covalently linked wall proteins. An important aspect of these differences lay in the practical absence of proteins recognized by two monoclonal antibodies, 1B12 and 3H8, which are considered valuable tools in the diagnosis of candidiasis in part because they normally react strongly with all strains. The C. albicans mutant, blocked in yeast-mycelium transition, was avirulent in a mouse model, although it was able to grow in animal tissues.

Serological differentiation of experimentally induced Candida dubliniensis and Candida albicans infections.

Using a rabbit model of systemic infection, we show that it is possible to differentiate infections caused by Candida dubliniensis and other Candida species by detecting the antibody response mounted by the infected animals. These results confirm our previous observation in a patient with C. dubliniensis candidemia and suggest that detection of C. dubliniensis-specific antibodies is useful in the diagnosis of invasive candidiasis caused by this yeast.

Compliance, satisfaction, and quality of life of patients with colorectal cancer receiving home chemotherapy or outpatient treatment: a randomised controlled trial.

OBJECTIVE: To compare chemotherapy given at home with outpatient treatment in terms of colorectal cancer patients' safety, compliance, use of health services, quality of life, and satisfaction with treatment. DESIGN: Randomised controlled trial. SETTING: Large teaching hospital. PARTICIPANTS: 87 patients receiving adjuvant or palliative chemotherapy for colorectal cancer. INTERVENTIONS: Treatment with fluorouracil (with or without folinic acid or levamisole) at outpatient clinic or at home. MAIN OUTCOME MEASURES: Treatment toxicity; patients' compliance with treatment, quality of life, satisfaction with care, and use of health resources. RESULTS: 42 patients were treated at outpatient clinic and 45 at home. The two groups were balanced in terms of age, sex, site of cancer, and disease stage. Treatment related toxicity was similar in the two groups (difference 7% (95% confidence interval -12% to 26%)), but there were more voluntary withdrawals from treatment in the outpatient group than in the home group (14% v 2%, difference 12% (1% to 24%)). There were no differences between groups in terms of quality of life scores during and after treatment. Levels of patient satisfaction were higher in the home treatment group, specifically with regard to information received and nursing care. There were no significant differences in use of health services. CONCLUSIONS: Home chemotherapy seemed an acceptable and safe alternative to hospital treatment for patients with colorectal cancer that may improve compliance and satisfaction with treatment.

Differences in the Candida albicans antigenic expression after heat shock and infection.

Heat-shock and infection induce changes in protein expression in C. albicans. To investigate if these alterations induce changes in antigenicity, we have compared the reactivity mediated by IgA antibodies of protein extracts from a strain of C. albicans and the same strain recovered from an infected animal, both at 24 degrees C and 37 degrees C. The antigenic variability was detected mainly in antigens recognized by salivary IgA. Antigens of 223, 205, 180 and 140 kDa were over-expressed in both strains at 37 degrees C, indicating that variations due to heat shock were present before and after infection. The antigens were characterized as mannoproteins located at the outer side of the cell wall. An antigen of 61 kDa was also detected in which the expression decreased significantly after infection This was independent of heat shock.

Specific antibody response in a patient with Candida dubliniensis fungemia.

We report a case of fungemia caused by Candida dubliniensis in a non-HIV infected patient. Multiple cultures of blood performed over a period of 13 days were positive for this recently described yeast species. The C. dubliniensis isolates recovered were susceptible to fluconazole in vitro and the patient responded to intravenous therapy with this antifungal agent. It was possible to differentiate the fungemia caused by C. dubliniensis in this patient from that caused by C. albicans in other patients on the basis of the analysis of the antibody response since the C. dubliniensis-infected patient exhibited a characteristic and specific antibody response against a cell wall component of 160-170 kDa.