Filamentous Fungi.

Filamentous mycoses are often associated with significant morbidity and mortality. Prompt diagnosis and aggressive treatment are essential for good clinical outcomes in immunocompromised patients. The host immune response plays an essential role in determining the course of exposure to potential fungal pathogens. Depending on the effectiveness of immune response and the burden of organism exposure, fungi can either be cleared or infection can occur and progress to a potentially fatal invasive disease. Nonspecific cellular immunity (i.e., neutrophils, natural killer [NK] cells, and macrophages) combined with T-cell responses are the main immunologic mechanisms of protection. The most common potential mold pathogens include certain hyaline hyphomycetes, endemic fungi, the Mucorales, and some dematiaceous fungi. Laboratory diagnostics aimed at detecting and differentiating these organisms are crucial to helping clinicians make informed decisions about treatment. The purpose of this chapter is to provide an overview of the medically important fungal pathogens, as well as to discuss the patient characteristics, antifungal-therapy considerations, and laboratory tests used in current clinical practice for the immunocompromised host.

Early Streptococcus pneumoniae serotype changes in Utah adults after the introduction of PCV13 in children.

INTRODUCTION: Pneumococcal conjugate vaccines (PCV) have indirect effects due to decreased Streptococcus pneumoniae colonization in vaccine recipients. We sought to determine whether the introduction of PCV13 in children led to changes in the epidemiology and clinical manifestations of invasive pneumococcal disease (IPD) in adults. METHODS: We described demographics, comorbidities, clinical manifestations, and serotypes of IPD in Utah adults before (November 2009-February 2010) and after (March 2010-March 2012) the introduction of PCV13 in children. We also compare serotypes causing IPD in Utah adults and children. RESULTS: After the introduction of PCV13 in the childhood vaccine program, the proportion of IPD due to PCV13 exclusive serotypes decreased significantly in Utah adults (64-40%, p=0.009), primarily due to a decline in serotype 7F (36-15%, p=0.008). There were non-significant increases in IPD due to Pneumococcal polysaccharide 23 (PPV23) unique serotypes and non-vaccine serotypes, most notably serotype 22F. Changes in the proportions of vaccine and non-vaccine serotypes were similar in adults and children. Meningitis was more commonly due to non-vaccine serotypes relative to non-meningitis cases (47% vs. 18%, p=0.007). When stratified by sex, decreases in PCV13 serotype IPD were only noted in men (76-33%, p=0.001). CONCLUSIONS: Serotype epidemiology of IPD in adults closely follows that of children in the PCV13 era. Continued surveillance is needed to confirm whether replacement serotypes will lead to increases in pneumococcal meningitis and whether there are sex differences in the indirect effects of PCV vaccination in children.

Disseminated Mycobacterial Infection After International Medical Tourism.

International travel for the purpose of receiving medical care is increasing. We report a case of disseminated mycobacterial infection after fetal stem cell infusion.

Update on the epidemiology of pulmonary nontuberculous mycobacterial infections.

For decades, the incidence of pulmonary nontuberculous mycobacteria (NTM) has been reported to be increasing, yet formal epidemiological evaluation of this notion has been lacking until recently. Defining the epidemiology of NTM has been more challenging than with Mycobacterium tuberculosis (MTB). Unlike MTB, NTM are soil and water organisms, and infection is thought to be acquired from the environment rather than transmitted from person-to-person, with very rare exceptions. Due to their nearly ubiquitous presence in municipal water supplies, exposure to NTM is common. Further, NTM can colonize the respiratory tract without causing disease. NTM disease is not reportable to public health authorities; therefore, epidemiological and surveillance data are not readily available. Nonetheless, the prevalence of pulmonary NTM disease has increased dramatically in the United States and globally over the past 3 decades. Mycobacterium avium complex (MAC) accounts for the majority of NTM infections worldwide, but there is significant regional variability of various species. Additionally, novel species have been implicated in several countries in NTM pulmonary disease.

Evolving epidemiologic characteristics of invasive group a streptococcal disease in Utah, 2002-2010.

BACKGROUND: Invasive group A Streptococcus (GAS) infections are associated with substantial morbidity and mortality. Recent national surveillance data report stable rates of invasive GAS disease, although these may not capture geographic variation. METHODS: We performed a population-based, retrospective laboratory surveillance study of invasive GAS disease among Utah residents from 2002-2010. We used Intermountain Healthcare's electronic medical records and data warehouse to identify patients from whom GAS was isolated by culture. We defined clinical syndromes of invasive GAS disease on the basis of International Classification of Diseases, Ninth Revision codes. We abstracted demographic information, comorbidities, and microbiologic and laboratory findings. RESULTS: From 2002-2010, we identified 1514 cases of invasive GAS disease among Utah residents. The estimated mean annual incidence rate was 6.3 cases/100,000 persons, which was higher than the national rate of 3.6 cases/100,000 (P < .01). The incidence of invasive GAS disease in Utah rose from 3.5 cases/100,000 persons in 2002 to 9.8 cases/100,000 persons in 2010 (P = .01). Among children aged <18 years, the incidence of invasive GAS increased from 3.0 cases/100,000 children in 2002 to 14.1 cases/100,000 children in 2010 (P < .01). The increase in the pediatric population was due, in part, to an increase in GAS pneumonia (P = .047). The rate of invasive GAS disease in adults aged 18-64 years increased from 3.4 cases/100 000 persons in 2002 to 7.6 cases/100,000 persons in 2010 (P = .02). Rates among those aged ≥65 years were stable. The incidence of acute rheumatic fever declined from 6.1 to 3.7 cases/100,000 (P = .04). CONCLUSIONS: The epidemiologic characteristics of invasive GAS disease in Utah has changed substantially over the past decade, including a significant increase in the overall incidence of invasive disease-driven primarily by increasing disease in younger persons-that coincided temporally with a decrease in the incidence of acute rheumatic fever.

Streptococcus pneumoniae serotypes in Utah adults at the end of the PCV7 era.

While heptavalent pneumococcal conjugate vaccine (PCV) has decreased vaccine type invasive pneumococcal disease (IPD) nationwide, rapid serotype replacement and increasing parapneumonic empyema, has been reported in Utah children. The effect of pediatric vaccination on adults in this population is unknown. We identified 117 adults with IPD from the Intermountain Healthcare Central Laboratory between November 2009 and October 2010. We serotyped 61 (52%) stored isolates. We compared the serotype distribution of adult IPD isolates with that of pediatric isolates collected in 2009-2010. PCV7 serotypes were rare in adults (3%) and children (3%). Emerging 13-valent PCV serotypes 3, 7F, and 19A caused the majority of IPD in adults (63%) and children (56%). Fifty-one (84%) adult isolates were serotypes included in 23-valent polysaccharide vaccine and 66% in PCV13. Adult and pediatric IPD serotypes are closely associated in Utah. PCV13 vaccination in Utah children is likely to significantly impact IPD in Utah adults.

Distinguishing tuberculosis from nontuberculous mycobacteria lung disease, Oregon, USA.

To determine whether tuberculosis (TB) and nontuberculous mycobacteria (NTM) infection patients could be distinguished from one another with limited information, we compared pulmonary TB and NTM patients during 2005-2006. Our finding that age, birthplace, and presence of chronic obstructive pulmonary disease could differentiate TB and NTM disease could assist tuberculosis control efforts.