Orbital apex syndrome caused by Alternaria species: A novel invasive fungus and new treatment paradigm.

Orbital apex syndrome as a result of invasive fungal sinusitis is a disease entity most commonly found in immunocompromised patients. Infectious invasion affecting the orbital apex can have devastating visual and life-threatening consequences. Mucormycosis and Aspergillus species are the most common causes of such infections. Alternaria fungal sinusitis is a known entity, but its ability to cause an orbital apex syndrome has not yet been reported. Here, we present a case of orbital apex syndrome in an immunocompromised patient with invasive fungal sinusitis caused by Alternaria species. The patient underwent sinus washout and placement of an intraorbital catheter for local instillation of amphotericin B for 10 days, in addition to systemic antifungal treatment, with clinical resolution of infection. The use of an intraorbital catheter for local treatment of fungal infection may offer an exenteration-sparing treatment option in these patients.

Lomentospora prolificans fungemia in hematopoietic stem cell transplant patients: First report in South America and literature review.

Lomentospora prolificans is a filamentous fungus and an emerging pathogen in immunocompromised patients. It is encountered most commonly in Australia, Spain, and USA. We described the first case of Lomentospora prolificans fungemia in South America. The patient was a hematopoietic stem cell transplantation (HSCT) recipient who developed the infection 37 days after stem cells infusion. In addition, we performed a literature review of invasive lomentosporiosis in HSCT patients.

Fungaemia caused by obstructive renal candida bezoars leads to bilateral chorioretinitis: a case report.

BACKGROUND: Renal fungal bezoars are remarkably rare and mostly occur in immunodeficient patients. Only a small number of cases with immunocompetent patients have been published so far. The published treatment approaches comprised systemic antimycotic therapy and surgical or minimal invasive removal of the fungal balls. In some cases irrigation of the renal duct system with amphotericin B was performed. By obstruction of the urinary tract bezoars can lead to infected hydronephrosis and severe urosepsis with high lethality. Fungaemia can cause fungal colonization in different distant organs. Fulminant chorioretinitis and irreversible visual impairment can be the consequence of ocular fundus colonization. The following report highlights that a co-operation between urologists and ophthalmologists is absolutely indispensible in case of fungaemia. CASE PRESENTATION: Hereinafter we describe a case of an immunocompetent 56 years old woman, presenting with flank pain and shivering. The diagnosis turned out to be difficult due to initially negative urine culture. The fungaemia caused by obstructive nephropathy led to bilateral candida chorioretinitis. The patient was treated with intravenous amphotericin b and the bezoar was removed by percutaneous "nephrolitholapaxy". After two months, a follow up revealed the patient felt well, chorioretinal lesions regressed and urine culture did not show any fungal growth. CONCLUSION: To the best of our knowledge, this is the first case reporting on obstructive renal bezoars, which lead to haematogenous fungus spread and bilateral chorioretinitis. It points out that extensive ophthalmologic examination should be performed in case of fungaemia even if the patient is not suffering from any visual impairment.

Secondary free-flap reconstruction following ablation for acute invasive fungal sinusitis.

OBJECTIVE: Acute invasive fungal sinusitis (AIFS) is a frequently fatal infection for which extensive and debilitating surgical debridement is a mainstay of therapy. Resulting defects are often composite in nature, mandating free tissue-transfer reconstruction. Outcomes data for free flap reconstruction are limited. The purpose of this study was to examine surgical outcomes and survival in patients undergoing free flap transfer following invasive fungal sinusitis. STUDY DESIGN: Retrospective case series. METHODS: Between 1995 and 2015, patients undergoing operative debridement for AIFS were identified. Surgical records were used to identify survivors of acute infection who subsequently underwent free flap reconstructive surgery. Patient demographics, cause of immune compromise, defect description, flap type, perioperative complications, indications for revision surgery, functional outcomes, and long-term survival were reviewed. RESULTS: Forty-four patients were treated for AIFS, of those, 30 (68%) survived acute infection. Ten patients underwent maxillectomy, six with orbital exenteration, and were designated candidates for reconstruction. Eight patients underwent reconstruction. Median time from debridement to reconstruction was 67.5 days. Flap types included latissimus dorsi, scapula, anterolateral thigh, rectus, radial forearm, and fibula. Median follow-up was 7.7 months. No perioperative complications were encountered, and all subjects remained disease-free, able to speak and eat normally without prosthetic supplementation. Seven patients (87%) are currently alive. CONCLUSION: Reconstruction of defects left by invasive fungal sinusitis using free-tissue transfer resulted in successful flap survival, with no disease recurrence for all defects and flap types reviewed. Survivors of AIFS are able to tolerate midface reconstruction, with favorable functional outcomes and survival rates. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:815-819, 2017.

Early ultrasonographic finding of septic thrombophlebitis is the main indicator of central venous catheter removal to reduce infection-related mortality in neutropenic patients with bloodstream infection.

BACKGROUND: Septic thrombophlebitis increases patient morbidity and mortality following metastatic infections, pulmonary emboli, and/or septic shock. Central venous catheter (CVC) removal for occult septic thrombophlebitis challenges current strategy in neutropenic patients. PATIENTS AND METHODS: We prospectively evaluated infection-related mortality in 100 acute leukemia patients, with CVC-related bloodstream infection (CRBSI) after chemotherapy, who systematically underwent ultrasonography to identify the need for catheter removal. Their infection-related mortality was compared with that of a historical cohort of 100 acute leukemia patients, with CRBSI after chemotherapy, managed with a clinically driven strategy. Appropriate antimicrobial therapy was administered in all patients analyzed. RESULTS: In the prospective series, 30/100 patients required catheter removal for ultrasonography-detected septic thrombophlebitis after 1 median day from BSI onset; 70/100 patients without septic thrombophlebitis retained their CVC. In the historical cohort, 60/100 patients removed the catheter (persistent fever, 40 patients; persistent BSI, 10 patients; or clinically manifest septic thrombophlebitis, 10 patients) after 8 median days from BSI onset; 40/100 patients retained the CVC because they had not clinical findings of complicated infection. At 30 days median follow-up, one patient died for infection in the ultrasonography-assisted group versus 17 patients in the historical cohort (P<0.01). With the ultrasonography-driven strategy, early septic thrombophlebitis detection and prompt CVC removal decrease infection-related mortality, whereas clinically driven strategy leads to inappropriate number, reasons, and timeliness of CVC removal. CONCLUSION: Ultrasonography is an easy imaging diagnostic tool enabling effective and safe management of patients with acute leukemia and CRBSI.

[Extracorporeal life support given to a 16-year-old girl with cystic fibrosis, candida pneumonia and acute respiratory distress syndrome]. / Extrakorporale Membranoxygenierung bei einer jungen Patientin mit ARDS durch eine Pilzpneumonie bei Mukoviszidose.

HISTORY: Small bowel resection had to be performed because of an acute ileus in a 16-year old girl with mucoviscidosis. Severe respiratory insufficiency developed and she was transferred to the intensive care unit. INVESTIGATIONS: The clinical signs of a severe ARDS were demonstrated: Horowitz index < 200, pO (2) 57 mm Hg, FiO (2) 1,0, pCO (2) 82 mm Hg. Candida serology was positive (titer 1 : 5120), and there was a leukocytosis (20 000/µl), hypalbuminemia (14 g/l) and elevation of C-reactive protein (190 mg/l). TREATMENT AND COURSE: Because all non invasive treatment options had failed to improve the patient's condition, an extracorporal membrane oxygenation (ECMO) device was connected. Seven days later, after the pulmonary situation had improved, the device was successfully removed; the patient was discharged in a satisfactory condition after another month. CONCLUSION: ECMO is a another treatment option for serious ARDS in infection-related worsening of pulmonary cystic fibrosis.

Renal fungal ball: an unusual sonographic finding.

Fungal infections of the urinary tract tend to occur in the drainage structures instead of the renal parenchyma. In patients with systemic candidiasis, the kidney is vulnerable to the formation of cortical abscesses or obstructive intrarenal masses ("fungal balls"), usually at the ureteropelvic junction. We describe the case of a boy who presented with dysuria, fever, and chills. Sonographic examination showed mild enlargement of both kidneys and moderate dilatation of the pelvicaliceal system bilaterally. A well-defined, echogenic, oval, mobile mass measuring 2.5 x 2.0 cm, without posterior acoustic shadowing, was visualized in the pelvis of the left kidney. The upper and middle ureters were dilated bilaterally. A urine culture revealed hyphae of Candida albicans. The child received systemic antifungal therapy with fluconazole for 3 weeks. Follow-up sonography showed complete resolution of the mass (a fungal ball) with residual hydronephrosis.

Atypical mycobacteriosis as a complication of talc pneumoconiosis.

A 57 year old man, receiving compensation for talc pneumoconiosis since 1977, was admitted to hospital for the first time in 1987, with symptoms of weight loss, fever, dyspnoea and productive cough. A chest roentgenogram showed bilateral cavitation. Two years later, Mycobacterium xenopi was found in sputum cultures. Despite specific oral antibiotherapy, the patient's health deteriorated and he died in 1990. To the best of our knowledge, this is the first reported case of an association of talcosis with a M. xenopi pneumonia. The relative timing of the two diseases suggests that talc pneumoconiosis predisposed to the infection by M. xenopi.

Treatment of chronic disseminated Geotrichum capitatum infection with high cumulative dose of colloidal amphotericin B and itraconazole in a leukaemia patient.

A case of disseminated granulomatous Geotrichum capitatum infection is reported. A young patient with blastic crisis of chronic myelogenous leukaemia developed septicaemia caused by G. capitatum in the post-chemotherapy aplastic phase. Subsequently, disseminated infection of the liver, spleen, pancreas and kidneys was observed. Treatment with high cumulative doses of a lipid formulation of amphotericin B (Amphocil, 20.2 g in 11 weeks) and maintenance with itraconazole resolved clinical manifestations of G. capitatum granulomatous disseminated disease and controlled reactivation of the infection during the two subsequent courses of cytotoxic chemotherapy.

Fungal infection in a dissecting aneurysm of the thoracic aorta.

We describe a 54-year-old man who had an ascending aortic prosthetic graft and a porcine aortic valve prosthesis that were infected by Candida albicans. This infection led to the formation of a dissecting false aneurysm of the remaining transverse and entire descending thoracic aorta, and the man was admitted to our hospital for surgical treatment in February of 1991. Staged in situ graft replacement was performed using Borst's "elephant trunk" repair for the proximal aortic reconstruction and an open distal anastomosis technique for the distal repair. Candida albicans in the residual prosthetic graft was identified, and therapy with high-dose liposomal amphotericin B was initiated. The use of liposomal amphotericin B reduces the incidence of adverse effects and allows administration of higher doses than those possible with conventional amphotericin B therapy. Lifelong antifungal therapy is recommended for patients with C. albicans infection of prosthetic aortic grafts.