Laurie A. Proia

Clinical Practice Guidelines for the Management of Blastomycosis: 2008 Update by the Infectious Diseases Society of America

Evidence-based guidelines for the management of patients with blastomycosis were prepared by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replace the previous management guidelines published in the April 2000 issue of Clinical Infectious Diseases. The guidelines are intended for use by health care providers who care for patients who have blastomycosis. Since 2000, several new antifungal agents have become available, and blastomycosis has been noted more frequently among immunosuppressed patients. New information, based on publications between 2000 and 2006, is incorporated in this guideline document, and recommendations for treating children with blastomycosis have been noted.

Interlaboratory Comparison of Results of Susceptibility Testing with Caspofungin against Candida and Aspergillus Species

ABSTRACT Seventeen laboratories participated in a study of interlaboratory reproducibility with caspofungin microdilution susceptibility testing against panels comprising 30 isolates of Candida spp. and 20 isolates of Aspergillus spp. The laboratories used materials supplied from a single source to determine the influence of growth medium (RPMI 1640 with or without glucose additions and antibiotic medium 3 [AM3]), the same incubation times (24 h and 48 h), and the same end point definition (partial or complete inhibition of growth) for the MIC of caspofungin. All tests were run in duplicate, and end points were determined both spectrophotometrically and visually. The results from almost all of the laboratories for quality control and reference Candida and Aspergillus isolates tested with fluconazole and itraconazole matched the NCCLS published values. However, considerable interlaboratory variability was seen in the results of the caspofungin tests. For Candida spp. the most consistent MIC data were generated with visual “prominent growth reduction” (MIC2) end points measured at 24 h in RPMI 1640, where 73.3% of results for the 30 isolates tested fell within a mode ± one dilution range across all 17 laboratories. MIC2 at 24 h in RPMI 1640 or AM3 also gave the best interlaboratory separation of Candida isolates of known high and low susceptibility to caspofungin. Reproducibility of MIC data was problematic for caspofungin tests with Aspergillus spp. under all conditions, but the minimal effective concentration end point, defined as the lowest caspofungin concentration yielding conspicuously aberrant hyphal growth, gave excellent reproducibility for data from 14 of the 17 participating laboratories.

Voriconazole Use for Endemic Fungal Infections

ABSTRACT In a retrospective review of 24 patients with histoplasmosis, blastomycosis, or coccidioidomycosis treated with voriconazole (most for salvage therapy), the outcome was favorable (improved or stable) for 22 (95.8%) within 2 months of starting voriconazole and for 20 (83.3%) at the last follow-up. Prospective studies are required to determine its role in the treatment of endemic mycoses.

Blastomycosis of the Central Nervous System: A Multicenter Review of Diagnosis and Treatment in the Modern Era

BACKGROUND Central nervous system (CNS) involvement with Blastomyces dermatitidis is an uncommon and potentially fatal complication of blastomycosis. METHODS We retrospectively reviewed 22 patients with CNS blastomycosis at our institutions from 1990 through 2008 (13 proven, 5 probable, and 4 possible cases). RESULTS Magnetic resonance imaging was used in most patients, alone or in addition to computed tomography. CNS blastomycosis manifested as epidural abscess (1 of 22), meningitis (7 of 22), intracranial mass lesions (10 of 22), and concomitant intracranial mass lesions and meningitis (4 of 22). All patients received amphotericin B deoxycholate or a lipid formulation of amphotericin B as part of their treatment regimens. Most patients received amphotericin B followed by a prolonged course of oral azole therapy (voriconazole, fluconazole, or itraconazole). Four (18%) of 22 patients died during follow-up. CONCLUSIONS On the basis of these data, we recommend initial treatment with a lipid formulation of amphotericin B followed by a prolonged course of oral azole therapy, preferably voriconazole.

Successful Use of Voriconazole for Treatment of Coccidioides Meningitis

A 30-year-old Caucasian man developed fever, myalgia, and dry cough that lasted for 3 weeks. He works as a house painter in Phoenix, Ariz. Three months later, he developed right-sided headache, meningismus, and photophobia. A lumbar puncture (LP) revealed normal opening pressure, lymphocytic

A multicenter study of histoplasmosis and blastomycosis after solid organ transplantation

S.A. Grim, L. Proia, R. Miller, M. Alhyraba, A. Costas‐Chavarri, J. Oberholzer, N.M. Clark. A multicenter study of histoplasmosis and blastomycosis after solid organ transplantation.
Transpl Infect Dis 2011. All rights reserved

The Epidemiology of Blastomycosis in Illinois and Factors Associated with Death

BACKGROUND Blastomycosis is a systemic fungal disease that may be asymptomatic or progressive and may lead to death. METHODS In response to a reported increase in the number of cases of blastomycosis in Illinois, surveillance data reported to the Illinois Department of Public Health from January 1993 to August 2003 were analyzed and the medical records of 4 patients who died were reviewed. RESULTS Among the 500 cases reported, the median age of the patients was 43 years (range, 4-87 years), and 34 patients (7%) died. Higher rates of mortality were observed among persons who were black, who were > or =65 years of age, and who were male. The median time from onset of illness to diagnosis was 128 days (range, 12-489 days). Death was associated with a time from onset of illness to diagnosis of > or =128 days (OR, 2.1; 95% CI, 1.0-4.8). During the period from 1993 through 2002, the number of cases reported per year increased from 24 to 87 (P<.05). CONCLUSIONS The incidence of blastomycosis has been increasing in Illinois. To reduce mortality related to delay in diagnosis and treatment, medical providers need to be educated about blastomycosis, with an emphasis on symptom recognition, methods of diagnosis, and appropriate antifungal treatment.

Electron beam computed tomography for assessment of coronary artery disease in HIV-infected men receiving antiretroviral therapy

Hyperlipidemia has been seen in patients receiving protease inhibitor-based antiretroviral therapy, prompting concern that such patients are at risk for accelerated coronary artery disease (CAD). To assess the risk of CAD in antiretroviral-treated HIV-infected men, we quantified coronary artery calcium (CAC), a sensitive and established marker of subclinical CAD, using electron beam computed tomography (EBCT) of coronary vessels. Sixty HIV-infected men who met the following criteria (cases) were enrolled in the study: age of 40 years or older; naive to antiretroviral therapy or use of a stable antiretroviral regimen for >or=6 months (mean duration, 25.9 months; 41 patients were receiving protease inhibitor therapy); and no known CAD or no use of lipid-lowering agents. EBCT-derived CAC scores, serum lipid levels, history of antiretroviral therapy, and risk factors for CAD were obtained. Each case was compared with three age-, sex-, and race-matched HIV-negative controls randomly selected from a database including >9000 patients who had undergone EBCT. We determined differences in the proportion of cases and controls with CAC scores of >0 (detectable calcium) and clinically significant CAC for age range. There were no statistically significant differences between the number of cases and controls with detectable CAC (33% and 39%, respectively) and clinically significant CAC (18% and 17%, respectively). This study suggests that the rate of coronary atherosclerosis among HIV-infected patients who receive short-term antiretroviral therapy with or without protease inhibitors is not higher than that among age-, sex-, and race-matched HIV-negative controls. These results need to be confirmed in larger long-term studies, with controls well matched for coronary risk factors.

Phialemonium: An Emerging Mold Pathogen That Caused 4 Cases of Hemodialysis-Associated Endovascular Infection

Phialemonium species are emerging as fungal opportunistic pathogens of humans; infections caused by these fungi often have a fatal outcome. We report a series of 4 patients undergoing chronic hemodialysis who developed intravascular infection with Phialemonium curvatum. All isolates were of a distinct morphological type but were shown by partial ribosomal sequencing to be closely related to reference isolates of P. curvatum. Two patients in our case series died; both developed overwhelming infection associated with fungemia and endocarditis. Recent literature corroborates our experience that Phialemonium infection presents unique diagnostic challenges and that optimal management, particularly with regard to antifungal therapy, is not known.

Trichosporon inkin Peritonitis Treated with Caspofungin

ABSTRACT Trichosporon inkin is one of six pathogenic species of the genus Trichosporon and the etiologic agent of pubic white piedra. Trichosporon species have been reported as a cause of disseminated infections, particularly among immunosuppressed patients. We describe the third reported case of T. inkin peritonitis associated with peritoneal dialysis and the first to be treated with caspofungin.