A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.

OBJECTIVES: To describe the epidemiology, management and outcome of individuals with mucormycosis; and to evaluate the risk factors associated with mortality. METHODS: We conducted a prospective observational study involving consecutive individuals with proven mucormycosis across 12 centres from India. The demographic profile, microbiology, predisposing factors, management and 90-day mortality were recorded; risk factors for mortality were analysed. RESULTS: We included 465 patients. Rhino-orbital mucormycosis was the most common (315/465, 67.7%) presentation followed by pulmonary (62/465, 13.3%), cutaneous (49/465, 10.5%), and others. The predisposing factors included diabetes mellitus (342/465, 73.5%), malignancy (42/465, 9.0%), transplant (36/465, 7.7%), and others. Rhizopus species (231/290, 79.7%) were the most common followed by Apophysomyces variabilis (23/290, 7.9%), and several rare Mucorales. Surgical treatment was performed in 62.2% (289/465) of the participants. Amphotericin B was the primary therapy in 81.9% (381/465), and posaconazole was used as combination therapy in 53 (11.4%) individuals. Antifungal therapy was inappropriate in 7.6% (30/394) of the individuals. The 90-day mortality rate was 52% (242/465). On multivariate analysis, disseminated and rhino-orbital (with cerebral extension) mucormycosis, shorter duration of symptoms, shorter duration of antifungal therapy, and treatment with amphotericin B deoxycholate (versus liposomal) were independent risk factors of mortality. A combined medical and surgical management was associated with a better survival. CONCLUSIONS: Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis. Combined surgical and medical management was associated with better outcomes. Several gaps surfaced in the management of mucormycosis. The rarer Mucorales identified in the study warrant further evaluation.

Incidence, characteristics and outcome of ICU-acquired candidemia in India.

PURPOSE: A systematic epidemiological study on intensive care unit (ICU)-acquired candidemia across India. METHOD: A prospective, nationwide, multicentric, observational study was conducted at 27 Indian ICUs. Consecutive patients who acquired candidemia after ICU admission were enrolled during April 2011 through September 2012. Clinical and laboratory variables of these patients were recorded. The present study is an analysis of data specific for adult patients. RESULTS: Among 1,400 ICU-acquired candidemia cases (overall incidence of 6.51 cases/1,000 ICU admission), 65.2 % were adult. Though the study confirmed the already known risk factors for candidemia, the acquisition occurred early after admission to ICU (median 8 days; interquartile range 4-15 days), even infecting patients with lower APACHE II score at admission (median 17.0; mean ± SD 17.2 ± 5.9; interquartile range 14-20). The important finding of the study was the vast spectrum of agents (31 Candida species) causing candidemia and a high rate of isolation of Candida tropicalis (41.6 %). Azole and multidrug resistance were seen in 11.8 and 1.9 % of isolates. Public sector hospitals reported a significantly higher presence of the relatively resistant C. auris (8.2 vs. 3.9 %; p = 0.008) and C. rugosa (5.6 vs. 1.5 %; p = 0.001). The 30-day crude and attributable mortality rates of candidemia patients were 44.7 and 19.6 %, respectively. Logistic regression analysis revealed significant independent predictors of mortality including admission to public sector hospital, APACHE II score at admission, underlying renal failure, central venous catheterization and steroid therapy. CONCLUSION: The study highlighted a high burden of candidemia in Indian ICUs, early onset after ICU admission, higher risk despite less severe physiology score at admission and a vast spectrum of agents causing the disease with predominance of C. tropicalis.

A rare presentation of progressive disseminated histoplasmosis in an immunocompetent patient from a non-endemic region.

Histoplasmosis is an important systemic fungal infection in endemic areas. In India, the disease has been reported from several parts of the country, most cases being from eastern India considered to be endemic for the disease. There have been very few cases reported from the state of Andhra Pradesh, in the southern part of India. We report a case of progressive disseminated histoplasmosis presenting with bleeding manifestations in an immune competent patient from the state of Andhra Pradesh.

Microbiological spectrum of brain abscess at a tertiary care hospital in South India: 24-year data and review.

Intracranial abscesses are life-threatening infections that pose a diagnostic challenge not only to the neurosurgeon but also to the microbiologists. Detailed studies documenting the spectrum of infecting agents involved in brain abscesses are limited from India. Materials and Methods. This is a retrospective analysis of 352 samples from 1987 to 2010 analyzed at a tertiary care hospital in South India from 1987 to 2010, to document the changing trends with time. Results. The age of the patients ranged from 2 to 80 years, a larger number of males being affected. Otogenic infections were the most common cause while cryptogenic abscesses were 20%. Gram stain and culture positivity were 78% each. Gram-positive and negative facultative aerobes and obligate anaerobes were also on the rise. Unusual organisms, like Burkholderia pseudomallei, Salmonella typhi, Nocardia species, Cladosporium bantiana, Fonsecaea pedrosoi, Entamoeba histolytica, and Acanthamoeba were also isolated and/or detected from the brain abscesses aspirate or resected tissue. Summary. New and emerging pathogens associated with brain abscess, especially in immunosuppressed individuals, have renewed the necessity of an early detection, and it will be of great value in appropriate management of patients with brain abscess.

Mycetoma in South India: retrospective analysis of 13 cases and description of two cases caused by unusual pathogens: Neoscytalidium dimidiatum and Aspergillus flavus.

BACKGROUND: Mycetoma is a chronic suppurative and/or granulomatous inflammatory lesion of skin, subcutaneous tissue, fascia, and tendons caused by the traumatic inoculation of either fungal (eumycotic) or bacterial (actinomycotic) organisms present in the soil. The disease is characterized by triad of tumefaction, discharging sinuses, and grains. MATERIAL AND METHODS: Thirteen new cases of biopsy proven mycetomas were analyzed, retrospectively, from January 2000 to October 2009. Clinical parameters, bone involvement, microbiological properties, and histopathological features were evaluated. Categorization into eumycotic or actinomycotic was based upon features on hematoxylin and eosin stained sections with special stains. Therapeutic outcome was presented wherever available. RESULTS: There were eight actinomycetomas and five eumycetoma cases including 11 men and two women. Foot and lower extremities were the most common site of involvement (9 of 13, 69%). Culture results were available in 8 of 13 cases (61.5%). Madurella mycetomatis, Neoscytalidium dimidiatum, and Aspergillus flavus were the isolates among eumycetomas whereas Acinomadura madurae, Actinomadura pelletieri, and Nocardia species were the isolates among actinomycetomas. Two cases had underlying bone involvement. On follow-up, four of five eumycetoma cases showed partial improvement following surgery and antifungal therapy, one had amputation of the lower leg. Of the actinomycetomas, six of eight had dramatic improvement following sulfamethoxazole-trimethoprim based therapy, one had complete cure, and one was lost to follow-up. CONCLUSION: Strong clinical suspicion, exact categorization of lesion into eumycotic or actinomycotic along with culture correlation, is essential for prognosis and effective therapy.

Cerebral phaeohyphomycosis due to Cladophialophora bantiana.

Cladophialophora bantiana, a dematiaceous fungus and a member of the family Phaeohyphomycetes, is primarily a neurotropic fungus causing central nervous system (CNS) infection. We report a case of a well preserved, young adult male presenting with a capsuloganglionic abscess caused by C. bantiana, a rare entity. Diagnosis was made based on the mycology and histopathology findings of the aspirate from the abscess through a burr hole. The patient responded clinically to amphotericin B.

Sensitivity pattern of gram negative bacilli to three beta-lactam/beta-lactamase inhibitor combinations using the automated API system.

PURPOSE: To evaluate the spectrum of activity of three beta-lactamase inhibitors such as amoxicillin/ clavulanic acid, ticarcillin/ clavulanic acid and piperacillin/ tazobactam in comparison to cephalosporins against gram negative bacilli. METHODS: Gram-negative bacilli isolated from the clinical specimens received in the laboratory were included in the study. Using the API system (bioMiotarieux) during a one-year period, a total of 1,252 Enterobacteriaceae and 385 non-fermenters were evaluated. RESULTS: The percentage resistance of the Enterobacteriaceae isolates was 82.92% to amoxicillin/ clavulanic acid, 58.22% to ticarcillin/clavulanic acid and 22.44% to piperacillin/tazobactam respectively. Pseudomonas aeruginosa showed resistance of 96% to ticarcillin/ clavulanic acid and 61% to piperacillin/ tazobactam and Acinetobacter baumannii showed 49% resistance to ticarcillin/ clavulanic acid and 77% resistance to piperacillin/ tazobactam respectively. The isolates exhibited high resistance to all the generations of cephalosporins and the other groups of antibiotics except carbapenems. CONCLUSIONS: Piperacillin/tazobactam was found to be the most active combination of the three against Enterobacteriaceae and Pseudomonas spp. and ticarcillin/clavulanic acid against Acinetobacter spp. and Stenotrophomonas maltophilia.

Prevalence of central nervous system cryptococcosis in human immunodeficiency virus reactive hospitalized patients.

Central nervous system cryptococcosis is an important cause of mortality among human immunodeficiency virus (HIV) reactive patients. A retrospective study was conducted on a total of 1,863 HIV reactive hospitalized patients suspected of cryptococcal meningitis. Three hundred and fifty-nine cerebrospinal fluid specimens of these cases were screened for various cryptococcal investigations. Thirty-nine out of 359 (10.86%) showed a definite diagnosis of cryptococcosis with a mortality rate of 25.64%. Prevalence of cryptococcal meningitis in the total HIV reactive cohort was 2.09%. Concurrent cryptococcal meningitis and tuberculosis was seen in 33.3% cases. A high index of clinical suspicion and routine mycological surveillance is required to help an early diagnosis and appropriate therapy, as majority of patients respond well to therapy if treated early.

Serological evaluation of leptospirosis in Hyderabad Andhra Pradesh: a retrospective hospital-based study.

PURPOSE: Leptospirosis is a zoonotic disease with humans getting the infection either from rodent hosts or from domestic animals. Urine contaminated environment is the common source of infection. This is an under-reported disease in Andhra Pradesh. We report a retrospective hospital-based study on 55 patients with suspected leptospirosis. METHODS: A total of 55 serum samples were collected from patients with suspected leptospirosis and subjected to serological testing by LeptoTek Dri-dot, microscopic agglutination test (MAT) and IgM enzyme-linked immunosorbent assay (ELISA). Identification of the predominant infecting serotype was done using a panel of 12 serovars. RESULTS: MAT analysis of all the 55 samples identified all cases to be positive. The predominant serogroup was Icterohaemorrhagiae (68%) followed by Australis (22%), Autumnalis (8%) and Javanica (2%). LeptoTek Dri-dot showed a sensitivity of 96% as compared to MAT. IgM ELISA done on 32 samples showed a sensitivity of 86.7% compared to MAT. CONCLUSIONS: MAT helped to identify Icterohemorrhagiae as the predominant serovar in this study. Despite the small number of samples analyzed, the data obtained establishes a need for a prospective study in this region.

Serodiagnosis of dengue virus infection in patients presenting to a tertiary care hospital.

Dengue is an acute infectious disease of viral etiology. It is probably one of the most important arthropod borne viral disease in terms of human morbidity and mortality. The spectrum of disease ranges from self-limited dengue fever to more severe forms of dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS). Laboratory diagnosis of dengue virus infection mainly depends on detection of virus specific antibodies. The aim of the study was to correlate the serological results with clinical presentation in patients with a diagnosis of dengue. Eleven out of 15 (73.3%) patients with DHF and DSS had secondary antibody response and mortality was 100% in these patients.

Pathology of fungal infections of the central nervous system: 17 years' experience from Southern India.

AIMS: To describe the pathology of central nervous system (CNS) fungal infections with particular reference to India. METHODS AND RESULTS: This was a retrospective study from 1988 to 2004 constituting 130 cases. The diagnosis was based on morphology of biopsy/autopsy material. These included aspergillosis (n=73), zygomycosis (n=40), cryptococcosis (n=2), rhodotorulosis (n=1), candidiasis (n=5), maduramycosis (n=1), pheohyphomycosis (n=3) and mixed infections (n=5). Predisposing risk factors were present in 49 (38%) patients only. The majority of the patients were immunocompetent. The commonest risk factor was diabetes mellitus, the commonest route of infection was from a contiguous site and the commonest pathology was granuloma. Culture positivity was seen in only 31%. CONCLUSION: Environmental factors in tropical countries such as India play a significant role in the pathogenesis of CNS fungal infections.

Pulmonary zygomycosis in a diabetic patient.

We report a case of pulmonary zygomycosis in an adult male diabetic patient who presented with fever and altered sensorium initially and later developed streaky haemoptysis. Bronchoscopy showed picture of necrotizing pneumonia. Sputum was negative for fungal elements on admission but later bronchial wash and repeat sputum samples were positive by microscopy and culture showed growth of Rhizopus species. Immediately the patient was put on amphotericin B but had a bout of massive haemoptysis and succumbed. A high index of suspicion is needed for an early diagnosis and aggressive treatment of this infection in view of the high mortality rate.

Evaluation of Fungichrom 1: a new yeast identification system.

Advances in anti-fungal therapy necessitate the need for accurate identification of fungi especially yeasts to their species level for more effective management. Unlike the time consuming conventional methods of yeast identification using fermentation and assimilation patterns of various carbohydrates, the new commercialized yeast identification systems are simpler, rapid and are particularly easy to interpret. In our study, a new colorimetric yeast identification system-Fungichrom 1(International microbio, Signes, France) was evaluated against the conventional method to identify 50 clinical isolates of yeasts belonging to the genera -Candida, Cryptococcus, Geotrichum. 96% agreement was found between the two methods.

Isolation of a Nodulisporium species from a case of cerebral phaeohyphomycosis.

A fungal infection of the brain of a 55-year-old male patient is reported. The lesion and involved fungus were located exclusively in the right medial temporo-parietal region. The patient was successfully treated with surgical resection of the lesion and antifungal chemotherapy. Few pathogenic dematiaceous fungi exhibit neurotropism and can cause primary infection in the central nervous system (CNS). The etiological agent is described as a Nodulisporium species. To date Nodulisporium has never been reported as an agent of CNS infection in humans.