Caterina Cavanna

Cross-Reactivity of Fusarium spp. in the Aspergillus Galactomannan Enzyme-Linked Immunosorbent Assay

ABSTRACT Nine of 11 hematological patients with disseminated/deep-seated Fusarium infection tested at least twice for Aspergillus galactomannan (GM) had repeated positive results in the absence of Aspergillus isolation in culture. The centrifuged supernatants of 12 Fusarium isolates were tested by a GM enzyme-linked immunosorbent assay (EIA). All the isolates produced positive reactions when tested undiluted. These results show cross-reactivity of Fusarium spp. with Aspergillus GM that may constitute a drawback with respect to the specificity of the Platelia EIA.

INVASIVE FUNGAL INFECTIONS IN THE INTENSIVE CARE UNIT: A MULTICENTRE, PROSPECTIVE, OBSERVATIONAL STUDY IN ITALY (2006-2008)

Critically ill patients admitted to intensive care units (ICU) are highly susceptible to healthcare‐associated infections caused by fungi. A prospective sequential survey of invasive fungal infections was conducted from May 2006 to April 2008 in 38 ICUs of 27 Italian hospitals. A total of 384 fungal infections (318 invasive Candida infections, three cryptococcosis and 63 mould infections) were notified. The median rate of candidaemia was 10.08 per 1000 admissions. In 15% of cases, the infection was already present at the time of admission to ICU. Seventy‐seven percent of Candida infections were diagnosed in surgical patients. Candida albicans was isolated in 60% of cases, Candida glabrata and Candida parapsilosis in 13%, each. Candida glabrata had the highest crude mortality rate (60%). Aspergillus infection was diagnosed in 32 medical and 25 surgical patients. The median rate was 6.31 per 1000 admissions. Corticosteroid treatment was the major host factor. Aspergillosis was demonstrated to be more severe than candidiasis as the crude mortality rate was significantly higher (63% vs. 46%), given an equal index of severity, Simplified Acute Physiology Score (SAPS‐II). The present large nationwide survey points out the considerable morbidity and mortality of invasive fungal infections in surgical as well as medical patients in ICU.

Paranasal sinus fungus ball: diagnosis and management.

Paranasal sinus fungus ball is an extramucosal mycosis, usually occurring in immunocompetent people as a monolateral lesion. To review the literature data and to report the Policlinico S. Matteo, University of Pavia experience, 81 patients presenting paranasal fungus ball have been treated (January 1994 to May 2005). Twenty‐seven men and 54 women (19–91 years old; mean 49.4 years) were considered. Seventy‐three patients had a single sinus affected, but eight presented multiple localisations. Maxillary was the most involved sinus followed by sphenoidal and ethmoidal. Moulds have been isolated in 28/81 cases. Histology showed fungal colonisation but not invasion in all cases. Tomography showed bone erosion in 33.3% of patients. All have been treated only by functional endoscopic sinus surgery. Seventy‐seven of 81 patients have been cured. Four of 81 patients needed another surgical treatment. Follow up was between 6 and 132 months (average: 63 months). Fungus ball is a sinusal pathology caused by mycetes like Aspergillus spp. Histology confirms the fungal aethiology excluding tissue invasion. Mycological culture consented to identify the pathogenic mould in 34.5% of cases. Actually functional endoscopic sinus surgery is the gold standard for treatment of this pathology, and antifungal therapy is unnecessary.

Sphenoid sinus fungus ball: our experience

Background Fungal rhinosinusitis is a common disease of the paranasal sinuses. The fungus ball (FB) is defined as an extramucosal mycotic proliferation that fills one or more paranasal sinuses. Sphenoid sinus is an uncommon localization of this disease, as reported in the literature. This study describes our experience in the diagnosis and treatment of sphenoid sinus FB (SSFB), with a particular focus on the surgical approach to the sphenoid sinus. Methods We retrospectively analyzed the clinical records of patients affected by FB of the sphenoid sinus, who underwent endoscopic sinus surgery (ESS) in our institutions between 1995 and 2009. We described the surgical technique, the methods of mycological and histopathological evaluation, as well as the perioperative and postoperative management. Results From 1995 to 2009, 226 patients affected by sinonasal FB underwent ESS in our institutions. A sphenoid localization was found in 56 patients (24.78%; mean age, 62 years). Cephalea was the most common symptom, and 14.3% of patients complained of ocular symptoms. We performed a direct paraseptal sphenoidotomy in 31 patients (55.4%) and a transethmoidal sphenoidotomy in 25 patients (44.6%). Histology unveiled fungal hyphae with absent mucosal invasion in all cases. Cultural results revealed positivity for mycotic colonization in 26 cases (46.4%, most commonly Aspergillus fumigatus). Follow-up ranged from 12 to 181 months with a mean of 70.7 months. Conclusion The description of our experience in the diagnosis and treatment of SSFB underlines the importance of a precise diagnostic pathway in case of sphenoidal disease. Nowadays, in our opinion, the paraseptal direct sphenoidotomy represents the less invasive, fastest and most anatomically conservative approach to the sphenoid sinus in case of SSFB.

Invasive fungal sinusitis due to Bipolaris hawaiiensis.

A phaeohyphomycotic sinusitis due to Bipolaris hawaiiensis, observed in an immunologically competent patient, is reported and a review of data from the literature is given. The patient was successfully treated by surgical drainage and amphotericin B.

Resolution of invasive fungal sinusitis in immunocompromised patients: neutrophil count is crucial beside a combined medical and surgical approach.

Dear Editor, Invasive fungal sinusitis is a rare, severe infection, typically occurring in immunocompromised patients who have impaired neutrophil function or who have received longterm immunosuppressive therapy [1]. Haematological patients and among them, those affected by acute leukaemia and myelodysplastic syndrome are at higher risk [2]. The occurrence of this complication often compromises the therapeutic programme for the underlying haematological condition, necessitating a delay or cessation of chemotherapy with a subsequent high risk of relapse or progression. The acute fulminant form is characterised by its speed of evolution and is associated with a high mortality rate that reaches 100% in cases of intracranial mycotic dissemination [3]. The clinical onset is generally subtle and insidious; facial swelling or pain with or without fever must be promptly considered as possible signs of invasive sinusitis. Computed tomography (CT) evidence of pronounced thickening of the mucosa of the nasal cavity strongly suggests the diagnosis, which can be confirmed by identification of the pathogenic fungus in sinus tissues. Surgical debridement of the affected sinus is a necessary diagnostic and therapeutic procedure and must be combined with systemic antifungal therapy. The fungi most frequently involved are Aspergillus and Zygomicetes. Prognosis is related to various factors, such as the speed of diagnosis and treatment, the type of fungal infection [3], dissemination to the central nervous system, and complete neutrophil recovery [4]. The scarce information in the literature on invasive fungal sinusitis in immunocompromised patients highlights the importance and efficacy of a combined surgical and medical approach [5]. However, the factors with a major role in the evolution of the infection have not been discussed. We describe here seven cases of invasive fungal sinusitis, observed at our institution between November 2006 and December 2008, in patients affected by acute leukaemia (five patients with acute myeloid leukaemia and two with acute lymphoblastic leukaemia). These seven cases occurred among a total of 130 patients with acute leukaemia newly diagnosed in the same period. Table 1 summarises the characteristics of these seven patients and their infections. In all cases, the infection developed while the patients were severely neutropenic (neutrophil count< 500/mmc); the neutropenia was chemotherapy-related in six patients, while in one case of acute leukaemic transformation of a myelodysplastic syndrome, it was an expression of the patient’s haematological disease. This last patient had never been treated before; two out of the other six patients had received only induction chemotherapy, while the other four patients had a prior history of more chemotherapy (1–8 lines of chemotherapy). Facial pain with or without facial swelling was the initial symptom in all cases, associated with fever in six out of the seven patients. CTscanning, which P. Zappasodi (*) :M. Rossi : C. Castagnola :A. Corso : M. Bonfichi :M. Lazzarino Division of Haematology, Foundation IRCCS Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy e-mail: p.zappasodi@smatteo.pv.it

Pulmonary Cladophialophora boppii Infection in a Lung Transplant Recipient: Case Report and Literature Review

Cladophialophora boppii is a dematiaceous fungus, which has been reported only rarely to be the cause of cutaneous infection. Herein we describe a C boppii parenchymal and bronchial infection in a lung transplant recipient. We also illustrate the clinicoradiologic patterns and review possible treatment options for these difficult infections.

Imported and autochthonous histoplasmosis in Bergamo Province, Northern Italy.

This paper reviews the Italian literature and illustrates the results of a survey on Histoplasma capsulatum var. capsulatum infection carried out in the Bergamo area of Italy over the last 10 y. During the period January 1989-July 1999, 7 patients were diagnosed as being affected by the H. capsulatum var. capsulatum infection. Until 1999 41 cases have been described in the Italian literature (9 before the 1980s, 6 in the 1980s and 26 in the 1990s). The epidemiological profile of histoplasmosis is well-defined: risk factors are activities such as visiting caves or building sites, travelling and immigration, and it affects both immunocompetent and patients with AIDS. However, in the past, the Italian soil was considered as a low-endemic pabulum for H. capsulatum var. capsulatum and only a few autochthonous cases of histoplasmosis have been reported in Italy, specifically in the Po valley. In the present series, the identification of new cases in the Po valley in Lombardy suggests the possible autochthonous presence of histoplasmosis in Italy.This paper reviews the Italian literature and illustrates the results of a survey on Histoplasma capsulatum var. capsulatum infection carried out in the Bergamo area of Italy over the last 10 y. During the period January 1989-July 1999, 7 patients were diagnosed as being affected by the H. capsulatum var. capsulatum infection. Until 1999 41 cases have been described in the Italian literature (9 before the 1980s, 6 in the 1980s and 26 in the 1990s). The epidemiological profile of histoplasmosis is well-defined: risk factors are activities such as visiting caves or building sites, travelling and immigration, and it affects both immunocompetent and patients with AIDS. However, in the past, the Italian soil was considered as a low-endemic pabulum for H. capsulatum var. capsulatum and only a few autochthonous cases of histoplasmosis have been reported in Italy, specifically in the Po valley. In the present series, the identification of new cases in the Po valley in Lombardy suggests the possible autochthonous presence of histoplasmosis in Italy.

Invasive fungal rhinosinusitis in adult patients: Our experience in diagnosis and management

BACKGROUND This paper describes our experience in the management of acute and chronic invasive fungal rhinosinusitis (IFRS) in adults. METHODS Medical files of all patients aged >18 years treated in our institutions for IFRS from 2002 to 2013 were retrospectively reviewed. RESULTS A total of 18 cases (10 acute and 8 chronic) were recorded. In acute form, haematological malignancies represented the principal comorbidity (100%), while in chronic form this was diabetes mellitus (87.5%). All patients received systemic antifungal agents. Endoscopic sinus surgery was performed in 16/18 patients (88.9%). Among patients with an acute IFRS, 4/10 died of fungal infection (40%), on the other side 2/8 patients with chronic IFRS died of the evolution of the mycosis (25%). CONCLUSIONS Acute and chronic IFRS are different entities: in acute form, prognosis is poor, so therapy should be promptly performed, although host immune status and evolution of the haematological disease are key factors for the outcome. In chronic form, a wide surgical excision of the disease is recommended in order to obtain a complete removal of fungal infection. In both forms, early clinical findings are non-specific and ambiguous, so diagnosis depends on a high index of suspicion, taking into account predisposing factors.

Biofilm production by Candida isolates from a survey of invasive fungal infections in Italian intensive care units

Laboratorio, IRCCS Ospedale San Matteo, Pavia, ItalyCandida biofilm consists of a network of yeasts,hyphae, and/or pseudohyphae embedded in a matrixof polysaccharides, proteins, and other undefinedcomponents. The Candida biofilm lifestyle results inprotection of the fungus from host defences andantifungal drug resistance.