First report of Cryptococcus laurentii meningitis and a fatal case of Cryptococcus albidus cryptococcaemia in AIDS patients.

We report the first case of Cryptococcus laurentii meningitis and a rare case of Cryptococcus albidus cryptococcaemia in AIDS patients. Both infections were treated with amphotericin B and flucytosine. The C. laurentii meningitis was controlled after 2 weeks of treatment with no evidence of infection 20 months later. The patient with C. albidus cryptococcaemia, despite the amphotericin B/flucytosine combination therapy, died on the 14th day of treatment. The minimum inhibitory concentrations (MICs) for C. laurentii, as determined by Etest on RPMI 1640 agar, were 0.25 microg ml(-1) of amphotericin B, 1.25 microg ml(-1) flucytosine, 4 microg ml(-1) fluconazole, 0.50 microg ml(-1) itraconazole and 1.0 microg ml(-1) of ketoconazole. The MIC of amphotericin B for C. albidus was 0.5 microg ml(-1), flucytosine 1.25 microg ml(-1), fluzonazole 4 microg ml(-1), itraconazole 0.5 microg ml(-1) and ketonazole 0.25 microg ml(-1). The agreement of the amphotericin B MIC values obtained in antibiotic medium 3 by the broth microdilution method, with those obtained on casitone medium by Etest, was within a two-dilution range for both isolates. C. laurentii may cause meningitis and may also involve the lungs in AIDS patients.     

In vitro antifungal susceptibility testing of Candida blood isolates and evaluation of the E-test method.

Fungal infections have dramatically increased in recent years, along with the increase of drug-resistant isolates in immunocompromised patients. Ninety eight Candida species obtained from blood cultures at the Tri-Service General Hospital, Taiwan, from 1998 to 2000 were studied. These included 50 Candida albicans, 13 Candida glabrata, 24 Candida tropicalis and 11 Candida parapsilosis isolates. To investigate their susceptibility to commonly used antifungal drugs, minimum inhibitory concentrations (MIC) of amphotericin B, fluconazole, flucytosine, and ketoconazole were determined. Both the National Committee for Clinical Laboratory Standards reference broth macrodilution method and E-test were used in parallel. Ninety five isolates (95/98, 96.94%) were susceptible to amphotericin B at a concentration < or = 1 microg/mL. All isolates (100%, 98/98) were susceptible to flucytosine. Approximately 30% of these Candida isolates were resistant to fluconazole. The MIC for 90% of isolates (MIC90) values for both methods for these isolates were 0.5 microg/mL for amphotericin B, 32 microg/mL for fluconazole, 0.25 microg/mL for flucytosine (0.125 microg/mL by E-test method), and 4 microg/mL for ketoconazole. MIC for 50% of isolates (MIC50) values for these agents were 0.25, 2, 0.06, and 0.06 microg/mL, respectively. The essential agreement of MIC values within 2 dilutions for the 2 methods was 99.0% for amphotericin B, 90.8% for ketoconazole, 92.9% for fluconazole, and 91.8% for flucytosine. This study showed that E-test has equivalent performance to the broth macrodilution method and can be used as an alternative MIC technique for antifungal susceptibility testing.     

Interlaboratory evaluation of Etest method for testing antifungal susceptibilities of pathogenic yeasts to five antifungal agents by using Casitone agar and solidified RPMI 1640 medium with 2% glucose.

An interlaboratory evaluation (two centers) of the Etest method was conducted for testing the antifungal susceptibilities of yeasts. The MICs of amphotericin B, fluconazole, flucytosine, itraconazole, and ketoconazole were determined for 83 isolates of Candida spp., Cryptococcus neoformans, and Torulopsis glabrata. Two buffered (phosphate buffer) culture media were evaluated: solidified RPMI 1640 medium with 2% glucose and Casitone agar. MIC endpoints were determined after both 24 and 48 h of incubation at 35 degrees C. Analysis of 3,420 MICs demonstrated higher interlaboratory agreement (percentage of MIC pairs within a 2-dilution range) with Casitone medium than with RPMI 1640 medium when testing amphotericin B (84 to 90% versus 1 to 4%), itraconazole (87% versus 63 to 74%), and ketoconazole (94 to 96% versus 88 to 90%). In contrast, better interlaboratory reproducibility was determined between fluconazole MIC pairs when RPMI 1640 medium rather than Casitone medium was used (96 to 98% versus 77 to 90%). Comparison of the flucytosine MICs obtained with RPMI 1640 medium revealed greater than 80% reproducibility. The study suggests the potential value of the Etest as a convenient alternative method for testing the susceptibilities of yeasts. It also indicates the need for further optimization of medium formulations and MIC endpoint criteria to improve interlaboratory agreement.     

Global trends in the antifungal susceptibility of Cryptococcus neoformans (1990 to 2004)

The antifungal susceptibilities of 1,811 clinical isolates of Cryptococcus neoformans obtained from 100 laboratories in 5 geographic regions worldwide between 1990 and 2004 were determined. The MICs of amphotericin B, flucytosine, fluconazole, voriconazole, posaconazole, and ravuconazole were determined by the National Committee for Clinical Laboratory Standards broth microdilution method. Isolates were submitted to a central reference laboratory (University of Iowa) from study centers in Africa (5 centers, 395 isolates), Europe (14 centers, 102 isolates), Latin America (14 centers, 82 isolates), the Pacific region (7 centers, 50 isolates), and North America (60 centers, 1,182 isolates). Resistance to amphotericin B, flucytosine, and fluconazole was < or = 1% overall. Susceptibility to flucytosine (MIC, < or = 4 microg/ml) ranged from 35% in North America to 68% in Latin America. Similarly, only 75% of isolates from North America were susceptible to fluconazole (MIC, < or = 8 microg/ml) compared to 94 to 100% in the other regions. Isolates remained highly susceptible to amphotericin B (99% susceptibility at a MIC of < or = 1 microg/ml) over the entire 15-year period. Susceptibility to flucytosine (MIC, < or = 4 microg/ml) increased from 34% in 1990 to 1994 to 66% in 2000 to 2004. Susceptibility to fluconazole (MIC, < or = 8 microg/ml) increased from 72% in 1990 to 1994 to 96% in 2000 to 2004. Voriconazole, posaconazole, and ravuconazole all were very active (99% of isolates susceptible at MIC of < or = 1 microg/ml) against this geographically diverse collection of isolates. We conclude that in vitro resistance to antifungal agents used in the treatment of cryptococcosis remains uncommon among isolates of C. neoformans from five broad geographic regions and has not increased over a 15-year period.     

Epidemiology of candidaemia and antifungal susceptibility patterns in an Italian tertiary-care hospital

The epidemiological and antifungal susceptibility data for 94 episodes of candidaemia in an Italian tertiary-care hospital between January 2000 and August 2003 were evaluated by prospective laboratory-based surveillance. The incidence of fungaemia was 0.90 episodes/10 000 patient-days, and the most common species isolated were Candida albicans (40.4%), Candida parapsilosis (22.3%), Candida tropicalis (16.0%) and Candida glabrata (12.8%). Among 24 patients who received antifungal prophylaxis, non-albicans Candida spp. were more prevalent than C. albicans (p 0.012). The 30-day mortality rate was high (38.2%), particularly for haematological (71.4%) and solid-organ transplant patients (50.0%), and in individuals with C. tropicalis and C. glabrata bloodstream infections (60.0% and 50.0%, respectively). In-vitro susceptibility tests demonstrated that 95% of the isolates were susceptible to amphotericin B (MIC < 2 mg/L), 98.1% to posaconazole (MIC < 1 mg/L), 95.8% to flucytosine (MIC < 32 mg/L) and fluconazole (MIC < 64 mg/L), and 94.7% to itraconazole (MIC < 1 mg/L). Posaconazole was active (MIC 0.5 mg/L) against all three isolates of Candida krusei, which had reduced susceptibility to both fluconazole and itraconazole. Overall, non-albicans Candida spp. accounted for 60% of the episodes of candidaemia, which could be related to the use of antifungal prophylaxis. Resistance is still uncommon in Candida spp. recovered from blood cultures. The in-vitro activity of posaconazole is encouraging, and this agent could play an important role in the management of invasive candidiasis, including episodes caused by inherently less susceptible species such as C. krusei.     

Antifungal susceptibility of Cryptococcus neoformans to amphotericin B and fluconazole

Cryptococcus neoformans has emerged as an important opportunistic fungal pathogen in immunocompromised individuals. The therapeutic options of C. neoformans an opportunistic fungal pathogen include flucytosine, amphotericin B, and azole agents. However in the present scenario, emergence of resistance has been reported, hence this study was undertaken to evaluate antifungal susceptibility pattern of C. neoformans isolates from this southern part of India. Ten isolates of C. neoformans were tested against Amp B and fluconazole, of which 7 were susceptible to both and a single isolate of C. neoformans var gatti was resistant to both with MIC of 32mg/ml and 64mg/ml respectively.     

Fluconazole alone or combined with flucytosine for the treatment of AIDS-associated cryptococcal meningitis.

An all oral treatment for cryptococcal meningitis is attractive, particularly where amphotericin B use is impractical. Both fluconazole and flucytosine are available in oral formulations and have activity against Cryptococcus neoformans. We conducted a prospective phase II dose escalation study employing doses of fluconazole ranging from 800 to 2000 mg daily for 10 weeks used alone or combined with flucytosine at 100 mg/kg per day for the first 4 weeks. We found that increasing doses of fluconazole were associated with an increase in survival and a decrease in the time to conversion of the cerebrospinal fluid from culture positive to culture negative. Addition of flucytosine to fluconazole improved outcomes in each dosing cohort. High doses of fluconazole alone or combined with flucytosine were well tolerated.     

Chronic granulomatous disease of childhood. An unusual case of infection with Aspergillus nidulans var. echinulatus

Aspergillus nidulans var. echinulatus was the sole agent cultured from the left lung, a paraspinal abscess, left ribs, and thoracic vertebral bodies from a patient with chronic granulomatous disease. Hyphal elements were present in histologic sections of lung, vertebral bodies, and infected ribs along with granuloma formation. The patient was treated with two debridement procedures and insertion of a Harrington rod followed by a long course of amphotericin B, flucytosine, and daily white blood cell transfusions.     

Extensive genetic diversity within the Dutch clinical Cryptococcus neoformans population

A set of 300 Dutch Cryptococcus neoformans isolates, obtained from 237 patients during 1977 to 2007, was investigated by determining the mating type, serotype, and AFLP and microsatellite genotype and susceptibility to seven antifungal compounds. Almost half of the studied cases were from HIV-infected patients, followed by a patient group of individuals with other underlying diseases and immunocompetent individuals. The majority of the isolates were mating type α and serotype A, followed by αD isolates and other minor categories. The most frequently observed genotype was AFLP1, distantly followed by AFLP2 and AFLP3. Microsatellite typing revealed a high genetic diversity among serotype A isolates but a lower diversity within the serotype D set of isolates. One patient was infected by multiple AFLP genotypes. Fluconazole and flucytosine had the highest geometric mean MICs of 2.9 and 3.5 μg/ml, respectively, while amphotericin B (0.24 μg/ml), itraconazole (0.08 μg/ml), voriconazole (0.07 μg/ml), posaconazole (0.06 μg/ml), and isavuconazole (0.03 μg/ml) had much lower geometric mean MICs. One isolate had a high flucytosine MIC (>64 μg/ml), while decreased susceptibility (≥16 μg/ml) for flucytosine and fluconazole was found in 9 and 10 C. neoformans isolates, respectively.     

Evaluation of a capacitance method for direct antifungal susceptibility testing of yeasts in positive blood cultures

The feasibility of using a capacitance method (CM) for direct antifungal susceptibility testing of yeasts in positive blood cultures was evaluated. The CM used the same test conditions as those recommended by the National Committee for Clinical Laboratory Standards. After direct inoculation of positive culture broths into module wells (Bactometer; bioMérieux, Inc., Hazelwood, Mo.), the end-point determination was made by monitoring the capacitance change in the culture broths with Bactometer. The MIC of amphotericin B was the lowest concentration at which yeast growth was completely inhibited, while the MICs of ketoconazole, flucytosine, and fluconazole were the concentrations at which a >/=80% reduction in capacitance change was observed. The MICs of the four drugs against each blood isolate obtained on subculture plates were also determined by the macrodilution method. For 51 positive blood cultures tested, the percent agreement (+/-2 log(2) dilutions) between the CM and the macrodilution method were as follows: amphotericin B (98%), ketoconazole (92%), flucytosine (84%), and fluconazole (96%). The CM was further used for breakpoint susceptibility testing of fluconazole (8 and 64 microg/ml) and flucytosine (4 and 32 microg/ml) against yeasts in positive blood cultures. After testing of 74 specimens by the CM, flucytosine and fluconazole produced one (1.4%) major error and two (2.8%) minor errors, respectively. All yeasts that displayed resistance to flucytosine or fluconazole were detected within 24 h after direct inoculation of the positive broths into Bactometer. The CM may be useful for the rapid detection of antifungal resistance in positive blood cultures containing yeasts.     

Successful treatment of tongue aspergillosis caused by Aspergillus flavus with liposomal amphotericin B in a child with acute lymphoblastic leukemia.

A 5-year-old boy with acute lymphoblastic leukemia and probable pulmonary aspergillosis developed a hard, protuberant, white-yellow and aggressive elongated lesion on the left side of his tongue during a febrile agranulocytopenic episode. Despite the use of broad-spectrum antibiotics and other supportive therapies, the lesion increased to about 2x4 cm in size within two days and became grey-black with an erythemateous, irregular line. Partial excision of the tongue was performed and isolates recovered from the tongue biopsy specimen were identified as Aspergillus flavus. An increase in the systemic dose (7 mg/kg/day) and local intraoral delivery of liposomal amphotericin B was successful in treating the patient and resulted in improved clinical and laboratory findings. Herein, we document the observation of tongue aspergillosis in a leukemic child with probable pulmonary aspergillosis receiving liposomal amphotericin B therapy and the successful treatment of tongue aspergillosis with an increased dose (7mg/kg) of liposomal amphotericin B. To the best of our knowledge, this is the youngest patient with documented intraoral aspergillosis and only the second case of tongue aspergillosis caused by Aspergillus flavus.     

Phaeohyphomycosis due to Cladosporium cladosporioides.

Phaeohyphomycosis is a clinical entity caused by dematiaceous fungi. We describe a clinical case of phaeohyphomycosis due to Cladosporium cladosporioides in a 45-year-old white male, apparently healthy, human immunodeficiency virus-negative. The patient was treated with terbinafine for 9 months, with regression of a skin lesion. Three months after discontinuation of the therapy, there was a clinical and mycological relapse. After progression of the disease with inadequate treatment, there was no response to amphotericin B and flucytosine. Finally, we obtained a clinical response with itraconazole oral solution at 600 mg day(-1) for a 6-month period.     

Cryptococcal meningitis complicating systemic lupus erythematosus: two patients treated with flucytosine and amphotericin B.

Two fatal cases of cryptococcal meningitis complicating adrenocorticosteroid-treated systemic lupus erythermatosus are reported. In one patient who was treated with flucytosine alone, after an initial period of improvement cryptococci resistant to flucytosine were isolated, and subsequent amphotericine B treatment silated, and subsequent amphotericin B treatment did not alter the progress of the disease. In the second patient, who received both drugs concurrently, resistant cryptococci did not appear and the patient recovered sufficiently to return home. Flucytosine-resistant mutants could be demonstrated in vitro in the original cryptococcal isolated from both patients. The use of flucytosine and amphotericin B in combination is discussed.     

Geographic variation in the susceptibilities of invasive isolates of Candida glabrata to seven systemically active antifungal agents: a global assessment from the ARTEMIS Antifungal Surveillance Program conducted in 2001 and 2002

We examined the susceptibilities to amphotericin B, flucytosine, fluconazole, posaconazole, ravuconazole, voriconazole, and caspofungin of 601 invasive isolates of Candida glabrata and grouped the isolates by geographic location: North America (331 isolates), Latin America (58 isolates), Europe (135 isolates), and Asia-Pacific (77 isolates). Caspofungin (MIC at which 90% of isolates tested are susceptible [MIC(90)], 0.12 microg/ml; 100% of strains are susceptible [S] at a MIC of 相似文献   

Fatal pulmonary infection caused by the basidiomycete Hormographiella aspergillata.

A fatal case of a pulmonary infection caused by Hormographiella aspergillata, the anamorph of the mushroom Coprinus cinereus, is reported for a patient receiving treatment for a second relapse of acute lymphoblastic leukemia. The filamentous basidiomycete was identified with restriction fragment length polymorphism patterns of PCR-amplified internally transcribed spacers and small subunit ribosomal DNA with four restriction enzymes. The patient failed to respond to treatment with amphotericin B and itraconazole. The fungus was cultured from the lungs at autopsy: the MIC of amphotericin B for the fungus was low (0.5 mg/liter), and that of itraconazole was high (8 mg/liter).     

Combined surgical and antifungal treatment of a subcutaneous infection due to Paecilomyces lilacinus.

Paecilomyces lilacinus was the causal agent of a case of subcutaneous infection in a patient with liver cirrhosis. Surgical treatment in combination with systemic amphotericin B therapy led to complete recovery. Retrospectively performed microdilution testing revealed dose dependent in vitro susceptibility of the isolate to voriconazole (MIC = 2 g/ml) and terbinafine (MIC = 1 microg/ml).     

In vitro activity of amphotericin B,flucytosine and fluconazole against yeasts causing bloodstream infections

The in vitro activity of amphotericin B, flucytosine and fluconazole against 95 yeasts causing fungemia in a single institution over the last eight years was determined by a broth macromethod recommended by the National Committee for Clinical Laboratory Standards. All strains were inhibited by amphotericin B concentrations of 1 µg/ml. With flucytosine in most species the MIC50 was between 0.12 and 0.25 µg/ml and the MIC90 was between 0.25 and 1 µg/ml. One exception with flucytosine wasCandida krusei, with an MIC50 and MIC90 of 16 µg/ml and 32 µg/ml, respectively. Overall, 12 % of the isolates needed at least 8 µg/ml of fluconazole to be inhibited. Fluconazole was very active againstCandida albicans, Candida tropicalis andCryptococcus neoformans, with MIC50 ranging from 0.12 to 0.5 µg/ml and MIC90 of 1 µg/ml, and somewhat less active againstCandida parapsilosis (MIC50 of 1 µg/ml and MIC90 of 4 µg/ml). Fluconazole exhibited poor in vitro activity againstCandida krusei (MIC50 and MIC90 of 64 µg/ml) andTorulopsis glabrata (MIC50 of 4 µg/ml and MIC90 of 16 µg/ml). High MICs of fluconazole were found for four strains ofCandida albicans, one with an MIC of 4 µg/ml and three (5.7 %) with MICs of 16 µg/ml. Previous exposure to fluconazole could be demonstrated in two of these strains. Further work must be done in order to determine appropriate breakpoints of antifungal agents, to assess the clinical relevance of azole resistance in yeasts causing bloodstream infections and to identify risk factors for infections with azole-resistant yeasts.     

Multicenter comparison of the VITEK 2 antifungal susceptibility test with the CLSI broth microdilution reference method for testing amphotericin B, flucytosine, and voriconazole against Candida spp

A fully automated commercial antifungal susceptibility test system (VITEK 2; bioMérieux, Inc., Hazelwood, MO) was compared in three different laboratories with the Clinical and Laboratory Standards Institute (formerly the NCCLS) reference broth microdilution method (BMD) by testing 2 quality control strains, 10 reproducibility strains, and 426 isolates of Candida spp. against amphotericin B, flucytosine, and voriconazole. Reference BMD MIC endpoints were established after 24 and 48 h of incubation. VITEK 2 system MIC endpoints were determined spectrophotometrically after 9.1 to 27.1 h of incubation (mean, 12 to 14 h). Excellent essential agreement (within 2 dilutions) between the VITEK 2 system and the 24- and 48-h BMD MICs was observed for all three antifungal agents: amphotericin B, 99.1% and 97%, respectively; flucytosine, 99.1% and 98.8%, respectively; and voriconazole, 96.7% and 96%, respectively. Both intra- and interlaboratory agreements were >98% for all three drugs. The overall categorical agreements between the VITEK 2 system and BMD for flucytosine and voriconazole were 98.1 to 98.6% at the 24-h BMD time point and 96.9 to 97.4% at the 48-h BMD time point. The VITEK 2 system reliably detected flucytosine and voriconazole resistance among Candida spp. and demonstrated excellent quantitative and qualitative agreement with the reference BMD method.     

Hematogenous Candida spondylitis. A case report

A 58-year-old patient with neutropenia due to SLE developed spondylitis of the lumbar region caused by Candida albicans. The spondylitis was probably superinfected with Staphylococcus aureus. The initial one month's intravenous combination therapy with amphotericin B and flucytosine was discontinued because of fever reactions to amphotericin B, suspected myelosuppressive effect of flucytosine and insufficient clinical response. This therapy was followed by four months of oral ketoconazole and clindamycin with good results and without any side-effects.     

In vitro susceptibility of Cryptococcus gattii clinical isolates

The data available in the literature concerning Cryptococcus gattii in vitro antifungal susceptibility are contradictory. We have analyzed the activity of eight antifungal agents against 23 C. gattii clinical isolates and compared the susceptibility profiles with those of C. neoformans . MIC analysis (mg/L) revealed that C. gattii isolates were more susceptible to amphotericin B and flucytosine than were C. neoformans isolates . Fluconazole and other azole compounds showed high MIC values for C. gattii . Posaconazole displayed good activity. Further studies are required to ascertain the predictive value of the in vitro data presented here.