Malini R. Capoor

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.

Calcaneal osteomyelitis caused by exophiala jeanselmei in an immunocompetent child. A case report.

Fungal osteomyelitis of the calcaneus is very rare and has been reported in immunocompromised children1,2. We present the case of an eight-year-old immunocompetent child with fungal osteomyelitis of the calcaneus from the fungus Exophiala jeanselmei, which has been reported to be a very rare cause of mycetoma pedis. To our knowledge, isolated involvement of the calcaneus with fungal osteomyelitis has not been reported previously. The family of our patient was informed that data concerning the case would be submitted for publication. Fig. 1 Clinical photograph showing multiple sinuses and granulation tissue involving the left heel. An eight-year-old boy presented with a six-month history of pain, swelling, and multiple discharging sinuses over the heel of the left foot. There was no history of trauma or skin puncture, but there had been intermittent discharge of black-colored granules from the sinuses along with an associated occasional low-grade fever. There were no systemic or constitutional symptoms otherwise. He had received treatment in the form of local dressings and broad-spectrum antibiotics from his primary care physician, but these treatments had had no appreciable effect. Fig. 2 Radiograph of the left heel, showing the honeycomb appearance of the extensive loculated lytic areas of destruction within the body of the calcaneus. Clinical examination of the left heel revealed discharging sinuses with black, soft, …

Minimum inhibitory concentration of carbapenems and tigecycline against Salmonella spp.

Antimicrobial resistance in Salmonella spp. is of grave concern, more so in quinolone-resistant and extended-spectrum beta-lactamase (ESBL)-producing isolates that cause complicated infections. The MIC of azithromycin, ciprofloxacin, cefixime, cefepime, ceftriaxone, gatifloxacin, imipenem, levofloxacin, meropenem and ofloxacin (E-test strip) and tigecycline and faropenem (agar dilution) against 210 Salmonella spp. was determined. MIC(90) (defined as the antimicrobial concentration that inhibited growth of 90 % of the strains) of the carbapenems (imipenem and meropenem) for Salmonella Typhi and Salmonella Paratyphi A was 0.064 microg ml(-1). MIC(90) of faropenem was 0.25 microg ml(-1) for S. Typhi, S. Paratyphi A and Salmonella Typhimurium. The MIC(90) of azithromycin for all Salmonella spp. ranged from 8 to 16 microg ml(-1). Tigecycline showed an MIC(90) of 2 microg ml(-1) for S. Typhi, 1 microg ml(-1) for S. Paratyphi A and 4 microg ml(-1) for S. Typhimurium. We concluded that tigecycline and the carbapenems are likely to have roles in the final stage of treatment of quinolone-resistant and ESBL-producing multidrug-resistant salmonellae.

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.

Concomitant TB and cryptococcosis in HIV-infected patients

Four cases of concomitant tuberculosis and cryptococcosis infection in HIV-positive patients are described. As the HIV pandemic progresses and the proportion of patients with end-stage disease increases, a high suspicion of incidence and unusual forms of infections must always be kept in mind.

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.

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 manufacturers 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.

Concomitant Infections of Influenza A H1N1 and Disseminated Cryptococcosis in an HIV Seropositive Patient.

Respiratory viral infections, especially influenza have a potential to form a fatal association with cryptococcosis in the setting of compromised immunity. Considering the lethality of these two infections, we report an unusual case of dual infection of pandemic influenza A H1N1 and disseminated cryptococcosis in an HIV seropositive individual.

Cavitating lung disease due to concomitant drug resistant tuberculosis and invasive pulmonary Aspergillosis in a post-partum patient: A case report.

Many disorders can present as cavitating lesions in the lung. In this case report, a case of mixed infection with drug resistant tuberculosis and invasive pulmonary aspergillosis in a post-partum patient has been presented.

Facial eruption in a human immunodeficiency virus (HIV)‐seropositive patient

History A 37-year-old human immunodeficiency virus (HIV)seropositive male, resident of Delhi having migrated from Assam, taking highly active antiretroviral therapy (HAART), presented with sudden eruption of skincolored lesions on the face and neck for the last 15 days. The lesions appeared two months after starting HAART. There were multiple skin-colored discrete papules, many with central necrotic areas and crusts (Fig. 1). He had CD4+ T count of 13 cells/mm when HAART was initiated, which improved to 140 cells/mm at the time of presentation. Giemsa staining of the tissue showed yeast cells dividing by binary fission (Fig. 2a), and aspirated material grew flat moist greenish colonies with diffusible reddish pigment on Sabouraud’s dextrose agar (Fig. 2b). Skin biopsy revealed ill-formed epithelioid granulomas with both Langhans type and foreign body type giant cells and infiltrate of lymphocytes, histiocytes, plasma cells, and few scattered eosinophils in the superficial and mid-dermis (Fig. 3). Sections stained with silver methenamine and PAS revealed no organisms. 777 (a) (b)