Primary Vitrectomy versus Tap and Inject for Fungal Endophthalmitis: Meta-Analysis and Comparison with Data from a Reference Centre.

PURPOSE: We aimed to compare the visual outcomes after pars plana vitrectomy (PPV) versus tap and inject (T&I) in fungal endophthalmitis (FE) reported in the literature and to compare the findings from the literature with data from a reference centre. METHODS: We performed a systematic review and meta-analysis of studies reporting the use of PPV versus T&I in FE. We also performed a retrospective review of the clinical records of patients with endophthalmitis from a reference centre in Colombia. RESULTS: We included 13 studies with 334 eyes; 53.59% received PPV and 46.4% received T&I. The overall relative risk of improving ≥ 2 lines in PPV versus T&I was 0.98 (95% confidence interval [CI] 0.80-1.22; p = 0.88) with a mean difference of final visual acuity of 0.26 (95% CI 0.12-0.63; p = 0.18). There were no significant differences in subgroup analysis. Data from the reference centre included 32 endophthalmitis cases, 15.6% of which had a fungal aetiology (80% received PPV and 20% T&I). There were no significant differences in the subgroup analysis. CONCLUSIONS: Based on the findings from the literature and the reference centre, T&I is noninferior to PPV. This is the first meta-analysis in the literature evaluating these effects in FE. It is necessary to execute new prospective randomised controlled studies in patients with endophthalmitis.

Prosthetic joint infection due to Candida species: Case series and review of literature.

INTRODUCTION: The increase in the number of patients with prosthetic joints will entail a rise in the absolute number of infections associated with these procedures. Although less frequent, infections by Candida species are also expected to increase, and the clinical and surgical management of these cases is based on case reports and opinion of specialists. The objective of the present study was to review the available literature and describe the cases of prosthetic joint infection caused by Candida species in patients of the Institute of Orthopedics and Trauma of the University of São Paulo Faculty of Medicine Clinics Hospital (IOT-HCFMUSP) between 2007 and 2014. PATIENT CONCERNS: Eleven patients were diagnosed with prosthetic joint infection due to Candida with mean age of 65 years. The most frequent comorbidities were heart disease and diabetes mellitus, and the main personal antecedent was previous bacterial infection in the prosthetic joint. At least one risk factor for fungal infection was present in 73% of the patients. There was no difference between the prevalence of infections caused by Candida albicans and non-albicans Candida species, and there was bacterial co-infection in 55% of the cases. DIAGNOSIS: For building up the case series, patients with cultures of bone and joint specimens that were positive for Candida species and had a clinical diagnosis of prosthetic joint infection were included in the case series. INTERVENTIONS: Surgical debridement with removal of the prosthesis was the most frequently used surgical approach (45%). All patients were treated with monotherapy, and the most frequently used antifungal agent was fluconazole. The total duration of antifungal therapy was 6 months in 73% of the cases. OUTCOMES: After the initial management, 73% of the patients achieved clinical remission. CONCLUSION: The most indicated initial management was debridement with removal of the prosthesis, and the most used treatment regimen was fluconazole monotherapy. The most prevalent treatment duration was 6 months. The initial management led to a favorable outcome in 73% of the cases. DESCRIPTORS: Prosthetic joint infection, Candida, treatment, and diagnosis.

Severe fungal infections following blunt traumatic injuries: A 5-year multicenter descriptive study.

INTRODUCTION: The aggressive and timely treatment of post-traumatic fungal infections is the most efficacious way to reduce morbidity and mortality. Compared to the military trauma population, studies reporting on fungal infections in civilian trauma are not well described. The purpose of this study was to describe characteristics of civilian trauma patients who developed fungal infections and to identify common risk factors and report any delays between injury and treatment. METHODS: This was a five-year (1/1/2013-3/1/2018) retrospective, descriptive study across six level 1 trauma centers. All consecutively admitted trauma patients (≥18 years) with laboratory-confirmed fungal wound infections were included. Patients with solely candida wound isolates were excluded. Patient demographics, clinical wound and infection characteristics, organisms cultured, treatment modalities, length of stay, in-hospital mortality, and any diagnostic or treatment delays were described. RESULTS: Of the 54,521 trauma patients screened for fungal infection, 12 were identified. All patients suffered major injuries after blunt trauma (abbreviated injury score 3-5) and sustained wound contamination, and in nine patients, the cause of injury was motor vehicle. Six had open wounds/fractures on admission. The geographical region with the highest rate of fungal infection was Texas (n = 7), followed by Kansas (N = 3), then Missouri (N = 2). First symptoms of infection (leukocytosis or fever (n = 10)) presented a median of 6.3 (4.1-9.8) days after injury. Wound management entailed a combination of debridements (n = 8), negative pressure wound therapy (n = 9), amputation (n = 6), and antifungal treatment (n = 10). All fungal isolates identified from the wound site were hyphomycetes. A median of 2.1 (1.8-4.0) days passed from diagnosis to first antifungal treatment, and 3 patients died. CONCLUSIONS: Our study shows the challenges surrounding diagnosis and treatment of fungal infections secondary to trauma. Non-specific fungal infection symptoms, such as leukocytosis and fever, typically presented a week after injury. Vigilance for investigating risk factors and infection symptoms may help clinicians with more timely management of trauma patients with a severe fungal infection.

Endoscopic ventriculo-cisterno-ventricular approach in the treatment of bilateral trapped temporal horn related to fungal infection in a child: case report and review of the literature.

INTRODUCTION: Focal hydrocephalus including trapped temporal horn (TTH), isolated lateral and fourth ventricles, is caused by obstruction and/or adhesion related to various etiologies. With the advent of the neuroendoscope, endoscopic procedures have become an alternative in selected cases. CASE REPORT: A 2-year-old male from a rural town in México was referred to our institution because of multiple supra- and infra-tentorial abscesses and hydrocephalus. The patient had progressive deterioration and developed bilateral trapped temporal horn related to multi-septated hydrocephalus, so we performed an endoscopic ventricular-cistern-ventriculostomy through a single right temporal burr hole. POSTOPERATIVE COURSE: Bilateral TTH and multi-septated hydrocephalus were effectively treated with a single external ventricular drainage (EVD) catheter, from the right temporal horn to the left temporal horn through the interpeduncular cistern; after clamping the EVD for 3 days with no evidence of hydrocephalus, the EVD was removed. The size of the ventricles remained stable afterwards, and no clinical or radiological evidence of hydrocephalus was observed after 3 months of follow-up. DISCUSSION: Endoscopic ventriculocisternostomy is effective in selected cases of TTH. We know that dilatation of the temporal horn widens the window between the anterior choroidal artery and optic tract superiorly, and the posterior communicating and CN III inferiorly, making the described procedure feasible, even in the approach to the contralateral side. Even though this is a rare condition, we believe it is a safe and effective option to eliminate multiple shunts and/or to reduce the number of catheters needed to treat bilateral THH related to multi-septated hydrocephalus.

[Deep neck abscess. Factors related to reoperation and mortality]. / Absceso profundo de cuello. Factores asociados con la reoperación y mortalidad.

BACKGROUND: Deep neck abscesses are major complications that arise of odontogenic, pharyngeal, or cervicofacial foci, mainly in patients with morbidities that facilitate the spread to other spaces. Many of them require surgical treatment, and an appropriate evaluation and surgical drainage is required to obtain the best results. AIM: To identify factors which relate to reoperation and mortality in patient submitted to surgical treatment due to deep neck abscess. METHODS: Review of all patients with deep neck abscess who underwent surgical treatment in a Head and Neck Surgery Department in a third-level hospital during a two year period. RESULTS: There were 87 patients, 44 of which were female. The median age was 49 years old. Thirty-five patients (40%) had comorbidities, diabetes mellitus being the most common, found in 30 (34%) patients. Twenty-one patients (24%) required reoperation (primarily due to inadequate surgical drainage). The risk factors identified with it were presence of comorbidities (mainly diabetes mellitus) (p< 0.05), multiple deep neck spaces involvement (p< 0.001) and an ASA score of three or above (p< 0.01). Eight patients died, for a mortality of 9%. The factors related to mortality were multiple deep neck spaces involvement (p< 0.01), bilateral involvement (p< 0.05) and reoperation (p< 0.001). CONCLUSION: Deep neck abscesses appropriate evaluation and a complete surgical drainage of all deep space neck abscesses are primordial to avoid reoperation and improve survival.

Antecedentes: los abscesos profundos de cuello son complicaciones de infecciones, principalmente de origen odontogénico y de vías aéreas superiores, que afectan con mayor frecuencia a pacientes con morbilidades que favorecen la diseminación de la infección. Muchos requieren tratamiento quirúrgico, evaluación y drenaje apropiado para obtener los mejores resultados. Objetivo: identificar los factores relacionados con la reoperación y la mortalidad en pacientes con drenaje quirúrgico por absceso profundo de cuello. Material y métodos: estudio longitudinal, retrospectivo, observacional y comparativo efectuado con base en la revisión de todos los pacientes con absceso profundo de cuello que se operaron en un servicio de cabeza y cuello de un hospital de tercer nivel. Resultados: se estudiaron 87 pacientes, 44 de ellos eran mujeres. La mediana de edad fue de 49 años. El 40% tenían comorbilidades (35 pacientes) y la diabetes melltitus fue la más frecuente en 30 pacientes (34%). Se reoperaron 21 pacientes (24%), la mayoría por drenaje incompleto. Los factores de riesgo identificados fueron: comorbilidades (principalmente diabetes mellitus) (p< 0.05), mayor número de espacios afectados (p< 0.001) y una escala de ASA III o mayor (p< 0.01). La mortalidad fue de 9% (ocho pacientes). Los factores relacionados con mortalidad fueron: mayor número de espacios afectados (p< 0.01), afectación bilateral (p< 0.05) y reoperación (p< 0.001). Conclusión: en abscesos profundos de cuello la evaluación preoperatoria y el drenaje quirúrgico completo de todos los espacios afectados son primordiales para evitar la reoperación y mejorar la supervivencia.

[Endocarditis due to infection by Paecilomyces variotii]. / Endocarditis infecciosa por Paecilomyces variotii.

Fungal endocarditis is a cardiac complication that has been increasing throughout the world. We present a case of infective endocarditis by Paecilomyces variotii in a male patient with a prosthetic mitral valve. Successful treatment consisted of administration of amphotericin B (total dose 3670 mg) and mitral valve replacement. Only six cases have been reported previously, with a 100% mortality rate.

Rinossinusite fúngica em pacientes com infecção nasossinusal crônica / Fungal rhinosinusitis in patients with chronic sinusal disease

OBJETIVO: Estudar a rinossinusite fúngica em pacientes com infecção nasossinusal crônica. Nas últimas décadas houve aumento das infecções fúngicas, e a rinossinusite fúngica (RSF) tem sido mais freqüentemente diagnosticada. O conhecimento da flora fúngica, da sua prevalência e da apresentação sintomática em pacientes portadores de rinossinusite crônica (RSC) permitirá um melhor entendimento da doença, fato importante para a realização do diagnóstico, estabelecimento do tratamento e formulação do prognóstico. FORMA DE ESTUDO: clínico retrospectivo com coorte transversal. MATERIAL E MÉTODO: 62 pacientes com diagnóstico de RSF foram selecionados entre 890 portadores de RSC submetidos à cirurgia endoscópica. Avaliou-se anamnese, exame otorrinolaringológico com videoendoscopia nasal, TC dos seios da face e exames microbiológicos e histopatológico. RESULTADOS: A prevalência de RSF foi de 6,7% em portadores de RSC submetidos à cirurgia endoscópica dos seios paranasais, e o tipo de fungo mais encontrado foi do gênero Aspergillus. Bola fúngica foi encontrada em mais da metade dos casos, e RSFA, em mais de um terço dos pacientes. CONCLUSÕES: A evolução sintomática após a cirurgia endoscópica foi mais favorável nos portadores de bola fúngica, que necessitaram menor número de reintervenções.

Aim: Fungal rhinosinusitis in patients with chronic sinusal disease study. In the past decades, there has been an increase in fungal infections, and fungal rhinosinusitis (FRS) has been diagnosed more frequently. Knowing the fungal flora, its prevalence and symptomatic presentation in patients with chronic rhinosinusitis (CRS) will allow a better understanding of this disease, permitting a correct diagnosis, and treatment and formulating its prognosis. Study design: clinical retrospective with transversal cohort. Material and method: 62 patients diagnosed with FRS were selected among 890 cases of CRS undergoing endoscopic surgery. We assessed clinical history otolaryngologic examination with nasal videoendoscopy, CT scan, microbiologic and histopatologic tests. Results: The prevalence of FRS was 6.7 percent and the fungal type most frequently found was the gender Aspergillus. Fungal ball was found in more than half the cases, and allergic fungal rhinosinusitis (AFRS) in more than one third of the patients. Evolution after endoscopic sinus surgery was more favorable in patients with fungus ball, with a minor number of recurrences. Conclusions: The symptomatic evolution following endoscopic surgery was more favorable in patients with fungal ball, who require a lower number of re-interventions.

Fungal rhinosinusitis in patients with chronic sinusal disease.

AIM: Fungal rhinosinusitis in patients with chronic sinusal disease study. In the past decades, there has been an increase in fungal infections, and fungal rhinosinusitis (FRS) has been diagnosed more frequently. Knowing the fungal flora, its prevalence and symptomatic presentation in patients with chronic rhinosinusitis (CRS) will allow a better understanding of this disease, permitting a correct diagnosis, and treatment and formulating its prognosis. STUDY DESIGN: clinical retrospective with transversal cohort. MATERIAL AND METHOD: 62 patients diagnosed with FRS were selected among 890 cases of CRS undergoing endoscopic surgery. We assessed clinical history otolaryngologic examination with nasal videoendoscopy, CT scan, microbiologic and histopatologic tests. RESULTS: The prevalence of FRS was 6.7% and the fungal type most frequently found was the gender Aspergillus. Fungal ball was found in more than half the cases, and allergic fungal rhinosinusitis (AFRS) in more than one third of the patients. Evolution after endoscopic sinus surgery was more favorable in patients with fungus ball, with a minor number of recurrences. CONCLUSIONS: The symptomatic evolution following endoscopic surgery was more favorable in patients with fungal ball, who require a lower number of re-interventions.

Subcutaneous phaeohyphomycosis caused by Lasiodiplodia theobromae and successfully treated surgically.

While visiting Jamaica, a 50-year-old woman stumbled on an outdoor wooden staircase and sustained an injury to the right leg. The wound was cleaned topically and the patient was given antibacterial therapy. Five weeks later, in Canada, she presented with an ulcer at the injury site. An excisional biopsy showed copious broad, septate, melanized fungal filaments penetrating into tissue. Culture yielded a nonsporulating melanized mycelium. The isolate was strongly inhibited by cycloheximide and benomyl but grew at 37 degrees C. After 16 weeks cultivation on modified Leonian's agar at 25 degrees C, it developed pycnidia characteristic of Lasiodiplodia theobromae, a common tropical phytopathogen mainly known previously as a rare agent of keratitis and onychomycosis in humans. The patient was not given antifungal chemotherapy, and the ulcer, which had been broadly excised in the biopsy procedure, ultimately resolved after treatment with saline compresses. The six-month follow-up showed no sign of infection. This case, interpreted in light of previously reported cases, shows that on rare occasions L. theobromae is able to act as an agent of subcutaneous phaeohyphomycosis and that, when this occurs, debridement alone may be sufficient to eradicate it.

New advances in antifungal treatment.

Clinical aspects of treatment of invasive aspergillosis, infections caused by dematiaceous fungi, and mycoses caused by endemic, dimorphic fungi, are described in this review.

Entomoftoromicose intestinal: relato de caso / Intestinal entomophthoromycosis: a case report

A case of intestinal entomophthoramycosis caused by Entomophthorales in a man with 19 years-old, farmer and without associated disease. The patient was submitted to a intestinal resection and diagnosis was carried through after analysis of the surgical specimen. After a review of the literature, the clinical evolution, clinico-pathologic features, difficulties in diagnosis and treatment are discussed.

[Intestinal entomothoramycosis: report of a case]. / Entomoftoromicose intestinal: relato de caso.

A case of intestinal entomophthoramycosis caused by Entomophthorales in a man with 19 years-old, farmer and without associated disease. The patient was submitted to a intestinal resection and diagnosis was carried through after analysis of the surgical specimen. After a review of the literature, the clinical evolution, clinico-pathologic features, difficulties in diagnosis and treatment are discussed.

Trichosporon beigelii peritonitis associated with continuous ambulatory peritoneal dialysis

E relatado um caso de peritonite por Trichosporon beigelii em mulher submetida a tratamento por dialise peritoneal ambulatorial continuada. O diagnostico foi feito pelo exame direto e isolamento do fungo em cultivo do dialisado.

Transplante de córnea em úlcera micótica / Corneal transplantation in mycotic ulcer

Foi realizado um estudo retrospectivo de 8 pacientes portadores de ceratomicoses submetidos a transplante de córnea penetrante terapêutico, no sentido de avaliar as dificuldades técnicas, os resultados visuais e as principais complicaçöes. A indicaçäo do transplante foi feita nos casos de piora da lesäo apesar do tratamento clínico. A duraçäo da terapêutica medicamentosa com natamicina colírio e ketoconazol oral antes da cirurgia variou de 4 a 15 dias. Todos os pacientes apresentavam acuidade visual (AV) pré-operatória menor que movimento de mäos. 50% obtiveram AV pós-operatória igual ou maior que 20/50. As principais complicaçöes foram a catarata (50%) e a opacificaçäo do transplante (37,5%). Um paciente (12,5%) evoluiu para atrofia ocular e um (12,5%) para evisceraçäo, devido à progressäo da endoftalmite

[Treatment of cerebral fungus by ventriculoatrial shunt. Report of 5 cases]. / Tratamento do fungo cerebral por derivação ventriculo-atrial. Registro de 5 casos.

The causes and pathology of the cerebral fungi are analyzed. Five patients with this lesion were submitted to ventriculoatrial shunt. All were cured. According to the authors this is the best treatment for cerebral fungus, at present.

Occurrence of subcutaneous zygomycosis caused by Basidiobolus haptosporus in Brazil.

There were described the first three South American cases of subcutaneous zygomycosis caused by B. haptosporus. The patients were children from nearby towns lying just north of 13 degrees latitude S. The diagnosis was based on histopathological aspects plus cultural isolation of the fungus.

Occurrence of subcutaneous zygomycosis caused by Basidiobolus haptosporus in Brazil

There were described the first three South American cases of subcutaneous zygomycosis caused by B. haptosporus. The patients were children from nearby towns lying just north of 13 degrees latitude S. The diagnosis was based on histopathological aspects plus cultural isolation of the fungus.