"Tinea capitis caused by Microsporum canis: A case study of three family members in India, a non-endemic region.

INTRODUCTION: Tinea capitis, a common scalp infection primarily affecting children, is caused by keratinophilic dermatophytic fungi, notably Microsporum and Trichophyton species. Microsporum canis, primarily transmitted from cats and dogs to humans, is rarely reported in non-endemic regions like India. We report a cases involving three family members from Delhi, India, diagnosed with tinea capitis caused by Microsporum canis. The index case, a five-year-old boy, contracted the infection through contact with a cat, while his younger brother and sister acquired it through human-to-human transmission within the family. METHODS: Clinical examination, microscopic analysis, and molecular identification techniques confirmed the diagnosis. Antifungal susceptibility testing revealed sensitivity to itraconazole and terbinafine but resistance to griseofulvin. RESULTS: Treatment with oral terbinafine and topical ketoconazole cream led to successful outcomes for all three patients. Molecular typing confirmed clonality of the isolates, indicating human-to-human transmission. CONCLUSION: This case study underscores the significance of considering atypical sources of infection and human-to-human transmission in the diagnosis and management of tinea capitis caused by Microsporum canis in non-endemic regions. It emphasizes the necessity of thorough contact history assessment and appropriate antifungal therapy for effective control of the infection.

Diagnostic Utility of Galactomannan Enzyme Immunoassay in Invasive Aspergillosis in Pediatric patients with Hematological Malignancy.

OBJECTIVE: This study aims to determine the diagnostic utility of galactomannan enzyme immunoassay (GM EIA) in invasive aspergillosis (IA) in children with hematological malignancy (high risk population) in terms of sensitivity, specificity, negative predictive value (NPV) and positive predictive values (PPV) at various cut offs while validating the revised EORTC/MSG 2019 criteria in order to obtain the best cut-off. MATERIAL AND METHODS: For 100 pediatric patients, serum and respiratory samples were collected. Clinical, mycological workup (potassium-hydroxide mount, fungal culture) and GM EIA was done to classify proven, probable, and possible IA as per EORTC-MSG guidelines,2019. Sensitivity, specificity, PPV and NPV were calculated of GM indices at cut-off 0.5, 0.7 and 1, and validated with revised EORTC -MSG, 2019. RESULTS: Of 100 patients enrolled, 75 were diagnosed with ALL, 14 with AML, two with Hodgkin's, three had non-Hodgkin lymphoma, and six had undifferentiated leukemia. With routine mycological findings, 51 were classified as probable IA, 11 as possible IA, and 38 as no IA. Aspergillus flavus was the most prevalent on culture (56.9%, 29/51) followed by A. fumigatus (29%, 15/51) A. niger (7.8%, 4/51), A. terreus (3.9%, 2/51) and A. nidulans (2%, 1/51). GM EIA demonstrated sensitivity 82.3%, specificity 97.4%, PPV 98.1%, and NPV 77.1% at cut-off 0.67 when comparing probable/possible IA v/s no IA groups. The GM EIA had the best sensitivity (82.4%), specificity (81.8%), PPV (95.5%), and NPV (50%) at cut off 0.78 when the probable IA group was compared to the possible IA. Seven patients succumbed of whom 5 had GMI ≥ 2. CONCLUSION: This study deduces the optimal cut-off for serum GM EIA to be 0.67 obtained by ROC analysis when comparing possible and probable IA versus no IA and reinforces the definition of probable category of EORTC-MSG criteria, 2019. At 0.5 ODI the sensitivity (87.1%) and NPV (80.5%) are high, thus making it the most suitable cut-off for detecting true positive and ruling out IA respectively, in pediatric patients with hematological malignancy. GM EIA when performed adjunctive to clinico-radiological findings can prove to be screening, diagnostic and prognostic test for IA in pediatric hematological malignancy patients.

Battling the emerging epidemic of rhino-orbital-cerebral mucormycosis (ROCM) in COVID-19 pandemic: an interventional study.

PURPOSE: The most recent challenge being faced by the healthcare system during the worldwide COVID-19 pandemic is increase in the incidence rate of coinfection or superinfection; one of the most fatal being mucormycosis. This study aimed to estimate the risk factors, symptoms and signs, treatment outcome and prognosis of COVID-19-associated mucormycosis (CAM) patients. METHODS: This is an interventional study of 35 patients diagnosed and managed as CAM at a tertiary care centre in New Delhi, India. RESULTS: The mean age of patients was 40.45 ± 6 years with a male preponderance. CAM did not affect healthy individuals; the major risk factors included diabetes in 65.7% and injudicious steroid use in 51.4% patients. Orbital/facial edema was the most common presenting symptom (25.7%) as well as sign (28.57%). 68.5% patients were stage 3 (involvement of orbit) at presentation; 33.3% showed medial wall involvement. Treatment included intravenous Amphotericin and oral Posaconazole in all patients, paranasal sinus (PNS) debridement in 94.2%, orbital exenteration was done in 8 patients. Adjuvant retrobulbar Amphotericin B injection was administered in 12 patients with radiological resolution seen in 50% after 1 cycle. In patients with Stage 4 disease who underwent exenteration along with PNS debridement, survival rate was 100% at 30 days, and disease reduction occurred in 87.5% patients (P < 0.01). Overall, 68.5% responded to therapy, 8.5% showed progression and mortality rate was 22.85%, at a mean follow up period of 59.5 days. CONCLUSION: A multidisciplinary and aggressive approach is essential in the management of CAM patients.

Comparative analysis of airway invasive aspergillosis and endobronchial spread of tuberculosis on high resolution computed tomography.

The presence of tree-in-bud (T-I-B) pulmonary opacities on high resolution computed tomography (HRCT) in tuberculosis endemic areas is frequently regarded as a sine qua non for endobronchial tuberculosis (TB). That is not always the case, however. They can also be found in immunocompromised non-neutropenic patients with airway invasive aspergillosis (IA). Understanding the differences between the two conditions is thus critical for making an accurate diagnosis. This research aims to pinpoint those distinguishing characteristics. The study defines the distribution and morphology of T-I-B opacities and other ancillary pulmonary findings in the two conditions by performing a retrospective analysis of HRCT features in 53 immunocompromised patients with lower respiratory tract symptoms, 38 of whom were positive for TB on BAL fluid analysis and 15 confirmed IA by Galactomannan method. While the global distribution of T-I-B opacities affecting all lobes favoured TB (p=0.002), the basal distribution overwhelmingly favoured IA (p<0.0001). Morphologically, dense nodules with discrete margins were associated with TB, whereas nodules with ground-glass density and fuzzy margins were associated with IA. Clustering of nodules was observed in 18 TB patients (p=0.0008). Cavitation was found in 14 (36.84%) of TB patients but not in any of the IA patients. Peri-bronchial consolidation was found in seven (46.67%) of the IA cases and four (10.53%) of the TB cases (p=0.005, 0.007). The presence of ground-glass opacity and bronchiectasis did not differ significantly between the two groups. Not all T-I-B opacities on HRCT chest in immunocompromised patients in endemic TB areas should be reported as tubercular. Immunocompromised non-neutropenic patients with airway IA can be identified earlier with tree-in-bud opacities on HRCT chest, even in the absence of a nodule with halo, resulting in earlier and more effective management.

Biomedical Waste and Solid Waste Management in the Time of COVID-19: A Comprehensive Review of the National and International Scenario and Guidelines.

Biomedical waste generated during the diagnosis, isolation, and treatment of coronavirus disease 2019 (COVID-19) patients can also be the source of new infections; hence, it needs special consideration. Previous guidelines for the management of biomedical waste need to be revisited as the majority of COVID-19 patients remain asymptomatic and reside in community. Personal protective equipment (PPE) like masks, hazmat suits, gloves, and visors are now being used by the public also. Thus, the general household waste and disposables now make an exponential increase in the waste that can be considered an environmental hazard. In this article, the authors have tried to present the problems arising from COVID-19 waste and the recommendations put forth by competent authorities both nationally and internationally on COVID-19 waste management. Furthermore, in all the guidelines, it is crucial that the COVID-19 waste management follows environmentally sound principles and practices of biomedical waste management, with safe work and infection-control practices. Segregation of COVID-19 waste at source, awareness, and precautions at all steps of the waste-cycle are the only way ahead in this crisis.

Current perspectives of biomedical waste management in context of COVID-19".

COVID-19 pandemic and it's consequent biomedical waste is an unprecedented challenge worldwide. Biomedical waste generated during COVID-19 patient isolation, testing and care needs special consideration as it challenges the previous notion that only 15-20% of waste can be considered infectious. With establishment of new home quarantine facility, isolation/quarantine centres the chances of general waste getting contaminated with biomedical waste has increased exponentially. Through this systematic review the authors searched for all possible queries raised by different researchers on COVID19 waste management on Pubmed. A summary of all the different issues unique to COVID19 waste was prepared. Guidelines, rules and recommendation given by national and international agencies published till date were taken into account while trying to answer all the above questions raised by different studies. The key step in COVID19 waste management is segregation of biomedical waste from solid waste. Waste generated from COVID19 patients is like any other infectious waste, therefore creating public awareness about the COVID19 waste hazards and segregation at source is highlighted in all guidelines as a recommendation. These guidelines for management of waste generated during diagnostics and treatment of COVID-19 suspected or confirmed patients, are required to be followed in addition to existing practices under regulation. BMWM in COVID-19 context is a public health concern and is both a legal and social responsibility for all stakeholders.

Characteristics, outcome and risk factors for mortality of paediatric patients with ICU-acquired candidemia in India: A multicentre prospective study.

BACKGROUND: The epidemiology, clinical profile and outcome of paediatric candidemia vary considerably by age, healthcare settings and prevalent Candida species. Despite these differences, few comprehensive studies are undertaken. This nationwide study addresses this knowledge gap. METHODS: 487 children who contracted ICU-acquired candidemia at 23 Indian tertiary care centres were assessed for 398 variables spanning demography, clinical characteristics, microbiology, treatment and outcome. RESULTS: Both neonates (5.0 days; range = 3.0-9.5) and non-neonatal children (7.0 days; range = 3.0-13.0) developed candidemia early after ICU admission. Majority of neonates were premature (63.7%) with low birthweight (57.1%). Perinatal asphyxia (7.3%), pneumonia (8.2%), congenital heart disease (8.4%) and invasive procedures were common comorbidities, and antibiotic use (94.1%) was widespread. C tropicalis (24.7%) and C albicans (20.7%) dominated both age groups. Antifungal treatment (66.5%) and removal of central catheters (44.8%) lagged behind. Overall resistance was low; however, emergence of resistant C krusei and C auris needs attention. The 30-day crude mortality was 27.8% (neonates) and 29.4% (non-neonates). Logistic regression identified admission to public sector ICUs (OR = 5.64), mechanical ventilation (OR = 2.82), corticosteroid therapy (OR = 8.89) and antifungal therapy (OR = 0.22) as independent predictors of 30-day crude mortality in neonates. Similarly, admission to public sector ICUs (OR = 3.62), mechanical ventilation (OR = 3.13), exposure to carbapenems (OR = 2.18) and azole antifungal therapy (OR = 0.48) were independent predictors for non-neonates. CONCLUSIONS: Our findings reveal a distinct epidemiology, including early infection with a different spectrum of Candida species, calling for appropriate intervention strategies to reduce candidemia morbidity and mortality. Independent factors identified in our regression models can help tackle these challenges.

Disseminated Emergomyces pasteurianus Infection in India: A Case Report and a Review.

We report here a case of disseminated Emergomyces pasteurianus infection from India in a patient with AIDS. The patient presented with weight loss, dyspnoea and multiple non-tender skin lesions over face, neck and chest over 3 months. The case was diagnosed by microscopy, histopathology of sample and isolation of fungus from skin lesion, breast nodule, bone marrow and sputum. The identification of the isolates was confirmed by sequencing internal transcribed spacer region of rDNA, beta-tubulin, actin and intein PRP8. The patient responded well to intravenous amphotericin B deoxycholate followed by itraconazole therapy.

Antifungal stewardship with an emphasis on candidaemia.

Antimicrobial resistance is a global threat. To counter the growing menace of antibiotic resistance, several stewardship initiatives have been incorporated as part of the overarching strategy of healthcare delivery. In contrast, antifungal stewardship (AFS) has attracted less attention for several reasons, such as limited antifungal resistance and the lesser burden of fungal infections compared with bacterial infections. However, the emergence of resistant fungi, such as multidrug-resistant Candida auris, has provided impetus to AFS programmes. This review summarises existing data on AFS programmes, particularly in relation to invasive candidiasis, both in the empirical setting and in the setting of proven infection.

Comparative evaluation of galactomannan test with bronchoalveolar lavage and serum for the diagnosis of invasive aspergillosis in patients with hematological malignancies.

INTRODUCTION: Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in patients with hematological malignancies. In recent years, testing for values of galactomannan (GM) in serum and bronchoalveolar lavage (BAL) fluid has been investigated as a diagnostic test for IPA for such patients, but global experience and consensus on optical density (OD) cutoffs, especially for BAL galactomannan remains lacking. METHODS: We performed a prospective case-control study to determine an optimal BAL GM OD cutoff for IPA in at-risk patients. Cases were subjects with hematological diagnoses who met established revised definitions for proven or probable IPA established by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group (EORTC/MSG, 2008), without the use of BAL GM results. Exclusion criteria included the use of piperacillin/tazobactam and use of antifungals that were active against Aspergillus spp. before bronchoscopy. There were two control groups: patients with hematological diagnoses not meeting definitions for proven or probable IPA and patients with nonhematological diagnoses with no evidence of aspergillosis. Following bronchoscopy and BAL, GM testing was performed using the Platelia Aspergillus seroassay in accordance with the manufacturer's instructions. RESULTS: There were 51 cases and 20 controls. Cases had higher BAL fluid GM OD indices (ODIs) (mean: 1.27 and range: 0.4-3.78) compared with controls (mean: 0.26 and range: 0.09-0.35). Receiver operating characteristic analysis demonstrated an optimum ODI cutoff of 1.0, with high specificity (100%) and sensitivity (87.5%) for diagnosing IPA. CONCLUSIONS: Our results support BAL GM testing as a reasonably safe test with higher sensitivity compared to serum GM testing in at-risk patients with hematological diseases. A higher OD cutoff is necessary to avoid overdiagnosis of IPA.

Cytotoxic Drug Dispersal, Cytotoxic Safety, and Cytotoxic Waste Management: Practices and Proposed India-specific Guidelines.

This article deals with practices related to cytotoxic drug dispersal, cytotoxic safety, and cytotoxic waste management and attempts at India-specific guidelines for their dispersal and disposal. The articles related to cytotoxic drug dispersal, cytotoxic safety, and cytotoxic waste management were reviewed from PubMed and their applicability in Indian health-care facilities (HCFs) was also reviewed. All HCFs dealing with cytotoxic drugs should consider cytotoxic policy, patient safety and health-care worker safety, and environmental monitoring program as per the available international guidelines customized as per Indian conditions. Utmost care in handling cytotoxic waste is quintessential. The formation of India-specific cytotoxic guidelines requires the inputs from all stakeholders. Cytotoxic waste, cytotoxic safety, and cytotoxic waste management should be the subject of a national strategy with an infrastructure, cradle-to-grave legislation, competent regulatory authority, and trained personnel.

Current perspectives on biomedical waste management: Rules, conventions and treatment technologies.

Unregulated biomedical waste management (BMWM) is a public health problem. This has posed a grave threat to not only human health and safety but also to the environment for the current and future generations. Safe and reliable methods for handling of biomedical waste (BMW) are of paramount importance. Effective BMWM is not only a legal necessity but also a social responsibility. This article reviews the current perspectives on BMWM and rules, conventions and the treatment technologies used worldwide. BMWM should ideally be the subject of a national strategy with dedicated infrastructure, cradle-to-grave legislation, competent regulatory authority and trained personnel. Improving the management of biomedical waste begins with waste minimisation. These standards, norms and rules on BMWM in a country regulate the disposal of various categories of BMW to ensure the safety of the health-care workers, patients, public and environment. Furthermore, developing models for the monitoring of hospital health-care waste practices and research into non-burn eco-friendly sustainable technologies, recycling and polyvinyl chloride-free devices will go in long way for safe carbon environment. Globally, greater research in BMWM is warranted to understand its growing field of public health importance.

Evaluation of serum galactomannan enzyme immunoassay at two different cut-offs for the diagnosis of invasive aspergillosis in patients with febrile neutropenia.

BACKGROUND: Invasive aspergillosis (IA) is an increasingly common and fatal opportunistic fungal infection in patients with haematological diseases. Early diagnosis is difficult as mycological culture techniques have low sensitivity and the radiological tools have low specificity. Galactomannan enzyme immunoassay (GEI) detects galactomannan in the human serum with a reported sensitivity and specificity between 30% and 100%. AIMS: The aim of this study was to analyse the role of GEI in diagnosis of IA in patients with febrile neutropenia and to evaluate the role of GEI in the diagnosis of IA as per the revised (2008) European Organization for Research and Treatment of Cancer-Mycoses Study Group (EORTC-MSG) criteria at two different optical density (OD) cut-offs of 0.5 and 1.0. SETTING: This prospective study was conducted in Safdarjung Hospital, New Delhi, India. METHODS: GEI testing was performed in adult patients of febrile neutropenia with evidence of IA. Results at two different OD indices (ODIs) of 0.5 and 1.0 were analysed. The evaluation of the diagnostic parameter, that is, GEI was measured in terms of sensitivity, specificity and positive and negative predictive value and was validated with the revised (2008) EORTC-MSG diagnostic criteria of IA. RESULTS: One hundred and eleven patients had evidence of IA, of which 79 patients were GEI positive when cut-off ODI was 0.5, whereas with cut-off ODI 1.0, 55 patients were GEI positive. CONCLUSION: ODI of 1.0 should be considered as positive while in patients with OD between 0.5 and 1.0, repeat sampling from the patient is recommended.

Spectrum of fungal infection in head and neck cancer patients on chemoradiotherapy.

BACKGROUND: Radiotherapy for head and neck cancers (HNC) causes alteration of oral mucosal barrier predisposing it to colonization and infection. Such infections often result in pain and burning sensation thus contributing to major morbidity. OBJECTIVE: MATERIALS AND METHODS: Study was done on 50 patients of HNC treated with concurrent chemoradiotherapy. Three samples (throat, urine, blood) were collected for fungal culture and sensitivity. These samples were collected before the start of radiotherapy, during radiotherapy (2nd and 6th week) and post radiotherapy (10th week). RESULTS: Only 49 patients were available for analysis. Fungal infection was found in 27/49 patients (55.10%) out of which Non-albicans Candida was isolated in 18/49 (36.73%) and Candida albicans in 9/49 (18.36%) cases. About 66.66% (18/27) isolates were sensitive to fluconazole. Maximum isolation of yeast was during 6th week of radiotherapy. All grade 4 and 71.42% of grade 3 oral mucositis were found in patients who were positive for fungal infection. CONCLUSION: The spectrum of fungal species in throat swab was: Non-albicans Candida and Candida albicans observed in 36.73% and 18.36% of patients respectively. Higher rate of fungal colonization and infection was found in patients with grade 3/4 oral mucositis. Prophylactic fluconazole in HNC patients on concurrent chemoradiotherapy has the potential to reduce emerging invasive fungal infection and its associated morbidity.

Candida auris candidaemia in Indian ICUs: analysis of risk factors.

Objectives: To identify the risk factors associated with Candida auris candidaemia, as this fungus now poses a global threat. Methods: We performed a subgroup analysis of a previously reported study of 27 Indian ICUs. The clinical data of candidaemia cases due to C. auris and other Candida species were compared to determine significant risk factors associated with C. auris infection. Results: Of the 1400 candidaemia cases reported earlier, 74 (5.3%) from 19 of 27 ICUs were due to C. auris . The duration of ICU stay prior to candidaemia diagnosis was significantly longer in patients with C. auris candidaemia (median 25, IQR 12-45 days) compared with the non- auris group (median 15, IQR 9-28, P < 0.001). Based on logistic regression modelling, admission to north Indian ICUs [OR 2.1 (1.2-3.8); P = 0.012], public-sector hospital [OR 2.2 (1.2-3.9); P = 0.006], underlying respiratory illness [OR 2.1 (1.3-3.6); P = 0.002], vascular surgery [OR 2.3 (1.00-5.36); P = 0.048], prior antifungal exposure [OR 2.8 (1.6-4.8); P < 0.001] and low APACHE II score [OR 0.8 (0.8-0.9); P = 0.007] were significantly associated with C. auris candidaemia. The majority (45/51, 88.2%) of the isolates were clonal. A considerable number of isolates were resistant to fluconazole ( n = 43, 58.1%), amphotericin B ( n = 10, 13.5%) and caspofungin ( n = 7, 9.5%). Conclusions: Although C. auris infection has been observed across India, the number of cases is higher in public-sector hospitals in the north of the country. Longer stay in ICU, underlying respiratory illness, vascular surgery, medical intervention and antifungal exposure are the major risk factors for acquiring C. auris infection even among patients showing lower levels of morbidity.

Scedosporium apiospermum, an emerging pathogen in India: Case series and review of literature.

Scedosporium apiospermum is a rare cause of infection but is increasingly being reported among immunocompromised individuals around the world. We report two cases of S. apiospermum, one of keratitis and the other of nasal polyp both from immunocompetent patients. The two cases were successfully treated with voriconazole. It is important to diagnose such infections as their antifungal susceptibility to amphotericin B is variable.

Subcutaneous Phaeohyphomycosis Caused by Pyrenochaeta romeroi in a Rheumatoid Arthritis Patient: A Case Report with Review of the Literature.

Pyrenochaeta romeroi is a rare fungal agent of chronic, suppurative subcutaneous infections leading to mycetoma. It is an unusual cause of deep, non-mycetomatous infections. We herein present review of the literature along with a case of 61-year-old Indian female with rheumatoid arthritis who developed subcutaneous phaeohyphomycosis caused by Pyrenochaeta romeroi. It posed a diagnostic challenge, as the culture from fine-needle aspirate revealed a non-sporulating dematiaceous mould, which was the only supportive tool for its diagnosis and initiation of the therapy. However, it was the molecular sequencing which played the pivotal role in clinching the final aetiological diagnosis. To the best of our knowledge, this is the 20th case of Pyrenochaeta species infection occurring worldwide and first case report of subcutaneous phaeohyphomycosis caused by Pyrenochaeta romeroi in a rheumatoid arthritis patient.

Phaeohyphomycosis Due to Exophiala jeanselmei: An Emerging Pathogen in India--Case Report and Review.

We present a rare case of a 30-year-old woman who presented with a swelling on the lateral aspect of her left forearm, present since 6 months, adjacent to a 16-year-old burn scar. X-ray of elbow joint and forearm revealed the subcutaneous nature of the swelling. Giemsa and periodic acid-Schiff-stained smears and potassium hydroxide mount of fine-needle aspirate of the swelling revealed dematiaceous, branching, and septate fungal hyphae. Fungal culture of the aspirated pus showed growth of Exophiala jeanselmei. Histopathological examination revealed brown-coloured hyphae with foreign body giant cell reaction and palisading granulomas in the surrounding tissue. The patient was successfully treated with surgical excision of the swelling. All the cases of phaeohyphomycosis due to Exophiala spp. in India are also reviewed.

Disseminated Emmonsia pasteuriana infection in India: a case report and a review.

We report here the first case of disseminated Emmonsia pasteuriana infection in a patient with AIDS in India. The patient presented with weight loss, dyspnoea, left-sided chest pain and multiple non-tender skin lesions over face and body for 3 months. Disseminated emmonsiosis was diagnosed on microscopic examination and fungal culture of skin biopsy and needle aspirate of lung consolidation. It was confirmed by sequencing internal transcribed spacer region of rDNA, beta tubulin, actin, and intein PRP8. The patient responded to amphotericin B and itraconazole therapy.