Rungmei S. K. Marak

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.

Cavitary Pulmonary Zygomycosis Caused by Rhizopus homothallicus

ABSTRACT We report the first two proven cases of cavitary pulmonary zygomycosis caused by Rhizopus homothallicus. The diagnosis in each case was based on histology, culture of the causal agent, and the nucleotide sequence of the D1/D2 region of the 28S ribosomal DNA.

Oropharyngeal candidiasis and Candida colonization in HIV positive patients in northern India.

INTRODUCTION Oropharyngeal candidiasis (OPC) is the most common opportunistic fungal infection reported in human immunodeficiency virus (HIV) positive patients worldwide. This prospective study was undertaken to investigate OPC and Candida colonization (CC) and their correlation with CD4+ cell counts and antiretroviral therapy (ART) in HIV-positive patients. METHODOLOGY In total, 190 HIV-positive patients were enrolled for study in three groups as follows: Group A, 90 patients without ART; Group B, 100 patients undergoing treatment with ART; and Group C, 75 HIV-negative control patients. All HIV patients underwent clinical examination and were subjected to CD4+ cell counts. Swabs were collected from the oral cavity of all individuals and plated on Sabourauds dextrose agar. Identification of Candida species was performed by conventional methods. RESULTS Candida species were isolated in 84/190 (44.2%) and 20/75 (26.6%) of the HIV-positive subjects and controls respectively (p<0.01). OPC was noted in 21/190 (11%) of the HIV-positive patients. Candida albicans was the most frequently isolated species. Patients with CD4+ cell counts ≤ 200 cells/mm3 were significantly (p<0.001) more frequently colonized (37/63; 58.7%) and infected (18/21; 85.7 %) with Candida species. Candida species was seen in patients with CC and OPC with CD4+cell counts between 201 and 500 (21/63; 33.4% vs 3/21; 14.3%) and > 500 cell/mm3 (5/63; 7.9% versus 0/21 0%) respectively. CONCLUSION OPC and Candida colonization occur more frequently in HIV-positive patients with CD4+ cell counts ≤ 200 cell/mm3. ART significantly reduces OPC. C. albicans is the most frequently isolated species in both OPC and colonization, suggesting endogenous infection.

Pulmonary mucormycosis mimicking as pulmonary tuberculosis: a case report.

Pulmonary Mucormycosis is an uncommon disease caused by fungi of class Zygomycetes. It occurs predminantly in an immunodeficient host most common risk factor being diabetes mellitus. The lesions are localized in the lungs or the mediastinum. We are reporting a case of 70 years old male, having cough, haemoptysis, fever and chest pain. He was on antituberculosis treatment (RHEZ) for last 10 days and was later found to have Pulmonary Mucormycosis on further evaluation.

Apophysomyces elegans causing acute otogenic cervicofacial zygomycosis involving salivary glands

Zygomycosis is an invasive, life threatening fungal infection that usually affects immunocompromised hosts. In the head and neck region, rhino-orbito-cerebral zygomycosis is more common than the cervicofacial variety. We report the first case of otogenic cervicofacial zygomycosis caused by Apophysomyces elegans involving the salivary glands, an uncommon site of infection. The case began after a trivial trauma in a diabetic patient and despite surgical debridement and liposomal amphotericin B therapy, the patient died due to extensive involvement and metabolic/hemodynamic complications.

Invasive candidiasis in non neutropenic critically ill - need for region-specific management guidelines

Use of antifungal agents has increased over past few decades. A number of risk factors such as immunosuppression, broad spectrum antibiotics, dialysis, pancreatitis, surgery, etc., have been linked with the increased risk of invasive candidiasis. Though there are various guidelines available for the use of antifungal therapy, local/regional epidemiology plays an important role in determining the appropriate choice of agent in situations where the offending organism is not known (i.e. empirical, prophylactic or preemptive therapy). Developing countries like India need to generate their own epidemiological data to facilitate appropriate use of antifungal therapy. In this article, the authors have highlighted the need for region-specific policies/guidelines for treatment of invasive candidiasis. Currently available Indian literature on candidemia epidemiology has also been summarized here.

Invasive Aspergillosis of Anterior Skull Base in the Immunocompetent Host: Outcomes with a Combined Treatment Modality–An Institutional Experience

Objectives To study outcomes with voriconazole therapy in immunocompetent individuals following maximal safe endoscopic resection in invasive aspergillosis of the anterior skull base. Design Retrospective study of patients with chronic invasive aspergillosis including symptomatology, extent of disease, and response to voriconazole following maximal safe resection in immunocompetent individuals. Setting Tertiary care superspeciality referral center. Participants Ten consecutive patients of invasive aspergillosis of anterior skull base managed over a period of 2 years. Main Outcome Measures Symptom resolution with systemic voriconazole and radiologic evaluation following systemic antifungals as per predefined protocol. Conclusions Maximal safe resection via transnasal endoscopic route followed by systemic antifungals provides excellent outcomes in invasive skull base aspergillosis. Although liver and renal functions, besides visual acuity, need serial monitoring, voriconazole is well tolerated by our patients.

Isolated renal zygomycosis: novel diagnostic and prognostic criteria with experience of a tertiary care center.

Background: Isolated renal zygomycosis is a life-threatening infection and difficult to diagnose ante mortem due to varied presentations. Most reports in the literature are case reports. We are presenting our experience of 10 patients. Materials and Methods: Retrospective data of 10 consecutive patients with primary renal zygomycosis, including 2 post-transplant patients, in our tertiary care center was analyzed. Epidemiological characteristics, predisposing conditions, clinical presentation, diagnostic findings and treatment outcomes were recorded. Characteristic radiological findings were recorded. Localized disease was managed by supportive treatment or percutaneous drainage and extensive disease with unilateral or bilateral nephrectomy. Renal involvement was confirmed in all patients by histopathology. Results: The mean age of presentation was 35 years. Five patients who had bilateral renal involvement presented with oliguric acute renal failure, hematuria and abdominal pain. Three had unilateral renal disease and presented with flank pain and fever. The two post-transplant patients presented with fever and graft dysfunction. Even after aggressive treatment 5 patients died, accounting for a mortality rate of 50%. Conclusion: Isolated renal zygomycosis can be diagnosed with typical radiological findings, combined with clinical, laboratory and histopathological features. This study describes the newer ante mortem radiological diagnostic criteria and prognostic predictors of the disease.

Diagnostic pitfalls in cytological diagnosis of subcutaneous fungal infection in renal transplant recipients.

Renal transplant recipients (RTRs) are at increased risk of the development of a variety of skin infections that can result from graft‐preserving immuno‐suppressive therapy. In this study, we aimed to determine cytomorphological findings of fungal subcutaneous swelling in seven RTRs and to analyze diagnostic pitfalls in fungal cytology. A retrospective review of fine needle aspiration cytology (FNAC) smears of subcutaneous swelling with positive fungal elements in RTRs from 2008 to 2010 was performed. We had seven cases (all males; age range, 34–58 years, mean, 46.3 years). The time interval between the renal transplantation and appearance of swelling ranged from 8 to 19 months (mean, 13.4 months). The swelling was located on lower limb (six cases) and arm (one case). The lesion was solitary (six cases) and multiple (one case). The cytology of aspirated material showed branched septate fungal hyphae in six cases. These were well delineated on Periodic acid schiffs (PAS) and chromic silver methenamine (CSM) stains. One case showed presence of faint, thin walled, broad ribbon like hyphae. Culture of aspirated material was performed in four cases which grew phaeohyphomycosis in all. Histology of excised tissue showed numerous septate, branched, pigmented fungal elements suggestive of pheohyphomycosis in four cases and broad ribbon hyphae suggestive of zygomycosis in one case. All of our cases responded well with anti‐fungal treatment. Fungal infection can manifest as subcutaneous swelling in RTRs. It is often severe, rapidly progressive and difficult to diagnose. FNAC is an important diagnostic tool which is simple, cost effective and rapid method. Diagn. Cytopathol. 2012.

Isolated bilateral renal mucormycosis in apparently immunocompetent patients—a case series from India and review of the literature

ABSTRACT Background Isolated renal mucormycosis (IRM) is a potentially fatal disease affecting immunocompromised hosts. IRM affecting apparently immunocompetent patients is rare, with few previous reports, mostly from India. We describe 10 cases of bilateral IRM with no underlying risk factors. Methods We performed a retrospective analysis of cases of IRM from our hospital information system admitted between 2009 and 2016. We analyzed the data of this cohort of IRM, including epidemiological characteristics, clinical presentation, diagnostic procedures, treatment details and outcome. Results In all, 10 cases of bilateral IRM were identified. All of them were males with a mean age of 24.7 years (range 10–42). Most patients were initially managed as acute bacterial pyelonephritis with acute kidney injury. A total of eight patients were diagnosed antemortem. Diagnostic clues include sepsis not controlled with broad-spectrum antibiotics and enlarged kidneys with or without hypodensities on ultrasound/computed tomography imaging. Three patients also gave a specific history of passing white flakes in their urine. Eight patients received specific antifungal therapy with amphotericin B with or without posaconazole. Three patients in whom the disease was apparently confined to the pelvicalyceal system underwent local irrigation with Amp-B. One patient underwent bilateral nephrectomy. Four patients succumbed to the disease while five patients were successfully treated. One patient was discharged against medical advice. Conclusions IRM is a rare, life-threatening disease associated with high mortality even in immunocompetent individuals. Typical clinical and radiological findings and a high index of suspicion may help in early diagnosis, but definitive diagnosis requires histopathological and/or microbiological confirmation. Early and rapid diagnosis along with aggressive multidisciplinary management including initiation of specific antifungal therapy with or without surgical debridement is vital for a successful outcome.