The emergence of azole resistance in Aspergillus fumigatus complex in New Zealand.

BACKGROUND: Azole resistance in Aspergillus fumigatus (A. fumigatus) is increasing globally. A pan-azole-resistant isolate prompted genetic analysis of local azole-resistant isolates to determine resistance genotypes. METHODS: All A. fumigatus complex isolates were tested by the broth colorimetric micro-dilution method, Sensititre® YeastOne® (SYO) (TREK Diagnostic Systems, West Sussex, England). Epidemiological cutoff values derived from the Clinical & Laboratory Standards Institute method were used to determine the proportion of non-wild-type (non-WT) isolates (ie, those with an increased likelihood to harbour acquired mechanisms of resistance). Non-WT isolates were identified by ß-tubulin gene sequencing and the genotype for azole resistance was determined. The history of the patient with the first pan-resistant isolate was reviewed along with the treatment history of patients with azole-resistant strains. RESULTS: From January 2001 to August 2020, antifungal susceptibility testing was performed on 260 A. fumigatus complex isolates: six isolates were non-WT for one or more azole agent, two A. fumigatus sensu stricto and four other members within the species complex: two A. fischeri and two A. lentulus. There were three non-WT isolates for amphotericin B, three for itraconazole, five for posaconazole and five for voriconazole. All six non-WT strains were isolated in the past nine years (P<0.01), and four in the past three years. Azole-resistance genotyping for the A. fumigatus sensu stricto isolates detected amino acid changes at hot spots in the cyp51A gene: one at G54E and one at G138C. All six isolates were WT for caspofungin. Five of the six patients with azole-resistant strains had previous azole treatment, and the patient with the pan-azole-resistant strain had been on continuous azole treatment for 42 months preceding strain isolation. CONCLUSIONS: New Zealand can be added to the growing list of countries with azole-resistant A. fumigatus complex isolates, including pan-azole resistance in A. fumigatus sensu stricto. While uncommon and mostly found in cryptic species within the complex, azole resistance is increasing. The results provide a baseline for monitoring this emerging antifungal resistance trend in A. fumigatus in New Zealand.

An unexpected zoonosis: pulmonary dirofilaria infection mimicking pulmonary neoplasm.

Pulmonary dirofilaria infection is a rare condition in Australasia. We describe a case with radiographic findings concerning for pulmonary malignancy, with the unexpected pathological diagnosis of dirofilarial infection.

Shisha smoking as a possible cause of bilateral granulomatous lung lesions.

A 19-year-old male who regularly smoked tobacco shisha pipes presented with pleuritic chest pain, dyspnoea, and cough. He was found to have multiple bilateral lung nodules on computed tomography. A biopsy of the lung revealed necrotizing granulomatous inflammation but without evidence of infection, foreign body, vasculitis, or malignancy. There was spontaneous and complete clinical and radiographic resolution over the next 12 weeks following cessation of shisha use.

Primary pleural epithelioid hemangioendothelioma mimicking as a posterior mediastinal tumor.

A 41-year-old man with no previous asbestos exposure presented with 6 months of dull right lower chest pain and weight loss. The initial computed tomography (CT) scan was reported as showing a soft tissue thickening in the posterior mediastinum with non-specific nodules in the horizontal and oblique fissures. An endoscopic ultrasound-guided fine needle aspiration from the 12 × 25 mm heterogeneous posterior mediastinal mass was suspicious for a ganglioneuroma. The procedure was complicated by a large hemothorax requiring drainage. A subsequent positron emission tomographic CT revealed a moderately fluorodeoxyglucose avid area of pleural thickening extending from the sixth to ninth thoracic vertebral body in the paraspinal region along with nodules along the right horizontal and oblique fissures. A thoracoscopic biopsy of the pleural lesion confirmed a pleural epithelioid hemangioendothelioma. There was a 5-mm reduction in tumor thickness and improvement in his pain following 54 Gy of radiotherapy.

Audit of acute exacerbations of chronic obstructive pulmonary disease at Waitemata District Health Board, New Zealand.

AIM: To examine management and outcome of patients admitted to Waitemata District Health Board (WDHB) with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and determine performance according to evidence-based guidelines. METHODS: Retrospective chart review of all patients admitted to WDHB hospitals with primary diagnosis of AECOPD during May and October 2010. 195 admissions (156 patients) were audited. RESULTS: Patients comprised 72 females and 84 males; mean age 73.1 years. 96% were ever-smokers. 10% of patients had BMI <18 kg/m2 and 40% of these received no dietician input. Spirometry was recorded in 72% within the previous 5 years. Chest X-ray was performed in 96% in the first 24 hours and 33% had arterial blood gas (ABG) performed. Twenty-three patients (29%) had acute respiratory acidosis. Continuous positive airways pressure (CPAP) was used in 11 but none received non-invasive ventilation (NIV). Systemic corticosteroids and antibiotics were prescribed to 87% and 84% respectively. Ten percent of patients were referred for pulmonary rehabilitation (PR). Overall 90-day mortality was 6.7% with 3.1% inpatient mortality. Mean length of stay was 5 days. 90-day re-admission rate was 44%. CONCLUSION: Areas of good adherence to best practice guidelines. Room for improvement in use of NIV, ABG and spirometry measurement, and PR referral.

Delays in the assessment and management of primary lung cancers in South Auckland.

AIM: To determine the patient characteristics, referral patterns and delays in assessment and treatment of patients with primary lung cancer in South Auckland, New Zealand and compare with international standards. METHODS: Retrospective review of the clinical records of 80 patients referred to a secondary care respiratory service and diagnosed with primary lung cancer in 2004. RESULTS: Eighty-five percent of inpatient referrals and 48.5% of outpatient referrals were for advanced stage lung cancers. The median interval from receipt of outpatient referral to first chest physician assessment was 18 days, with median interval from the first chest physician assessment to bronchoscopy of 17 days and for staging CT chest of 16 days. For patients requiring a CT-guided percutaneous needle aspiration for diagnosis, there was a further median delay of 37 days after the initial CT scan. The median interval from the date of receipt of initial outpatient referral to diagnosis was 38 days, but for early stage lung cancers it was 54 days. The median interval to diagnosis for inpatient admissions was 6 days after the first respiratory assessment. CONCLUSION: The intervals for initial assessment, diagnosis and treatment of lung cancer in South Auckland do not meet the recommendations of international guidelines, especially for early stage lung cancers. Organisational and resource changes are required at each point in the diagnostic and management pathway to reduce delays.

Too much of a good thing, is it bad? Adrenaline on trial.

Adrenaline is vital in the treatment of severe allergic reactions (anaphylaxis), however it is often underutilised or inappropriately administered. Adrenaline treatment is not without risk and most adverse reactions to adrenaline occur when it is given in overdose or as an intravenous bolus. We report a case of myocardial injury and hypotension following inappropriate administration of adrenaline.

Comparison of abdominal aortic aneurysm diameter measurements obtained with ultrasound and computed tomography: Is there a difference?

OBJECTIVES: Accurate diameter measurements of abdominal aortic aneurysm (AAA) with both computed tomography (CT) and ultrasound (US) are essential for screening, planning surgical intervention, and follow-up after endovascular repair. Often there is a discrepancy between measurements obtained with CT and US, and neither limit of agreement (LOA) nor correlation between the two imaging methods has been clearly established. The purpose of this study was to assess the paired differences in AAA diameter measurements obtained with CT and US in a large national endograft trial. METHODS: CT and US measurements were obtained from an independent core laboratory established to assess imaging data in a national endograft trial (Ancure; Guidant, Menlo Park, Calif). The study included only baseline examinations in which both CT and US measurements were available. Axial CT images and transverse US images were assessed for maximal AAA diameter and recorded as CT(max) and US(max), respectively. Correlations and LOA were performed between all image diameters, and differences in their means were assessed with paired t test. RESULTS: A total of 334 concurrent measurements were available at baseline after endovascular repair. CT(max) was greater than US(max) in 95% (n = 312), and mean CT(max) (5.69 +/- 0.89 cm) was significantly larger (P <.001) than mean US(max) (4.74 +/- 0.91 cm). The correlation coefficient between CT(max) and US(max) was 0.705, but the difference between the two was less than 1.0 cm in only 51%. There was less discrepancy between CT(max) and US(max) for small AAA (0.7 cm, 15.3%) compared with medium (0.9 cm, 17.9%) and large (1.46 cm, 20.3%) AAA; however, the difference was not statistically significant. LOA between CT(max) and US(max) (-0.45-2.36 cm) exceeded the limits of clinical acceptability (-0.5-0.5 cm). Poor LOA was also found in each subgroup based on AAA size. CONCLUSIONS: Maximal AAA diameter measured with CT is significantly and consistently larger than maximal AAA diameter measured with US. The clinical significance of this difference and its cause remains a subject for further investigation.

The utility of color duplex ultrasonography in the diagnosis of temporal arteritis.

PURPOSE: Temporal arteritis (TA) is frequently diagnosed with nonspecific clinical characteristics, followed by a temporal artery biopsy to confirm the presence of vasculitis. Consequently, numerous screening surgical biopsies are performed with a high negative-biopsy rate. A prospective study was performed evaluating color duplex ultrasound scan (CDU) as the preferred method for the diagnosis of vasculitis in the evaluation of suspected TA. METHODS: Thirty-two patients with suspected TA on the basis of clinical criteria were evaluated with CDU before a temporal artery biopsy. The presence of a hypoechoic "halo," suggesting edema of the inflamed vessel, and inflammatory stenoses were noted. Histologic examinations of standard temporal artery biopsies then were performed, and the results were compared with the CDU findings. In addition, a metaanalysis was performed to identify articles related to the use of ultrasound scan in the detection of TA. RESULTS: All patients completed a bilateral CDU examination of the temporal arteries, and in 75% of patients biopsied, no evidence of vasculitis was found at histologic examination. When CDU examined for halo alone as the determinant for disease, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), compared with histologic confirmation of TA, were 85.7%, 92.0%, 75.0%, and 95.8%, respectively. With the criteria for a halo sign present, an inflammatory stenosis present, or both present on CDU, the sensitivity, specificity, positive predictive value, and NPV were 100%, 80.0%, 58.3%, and 100%, respectively. CONCLUSION: CDU is a superior noninvasive method of determining the presence of vasculitis when compared with routine surgical biopsy. Examination of the temporal artery with CDU can effectively predict which patient will need surgical biopsy. The utility of CDU in the diagnosis of TA is maintained by a high sensitivity in detecting patients with the disease and also by a high NPV that can eliminate patients who would not benefit from biopsy.