Mucormycosis in Iran: A six-year retrospective experience

Mucormycosis is a devastating infection caused by Mucoralean fungi (Mucormycotina, Mucorales). Data concerning the global epidemiology of mucormycosis are scarce and little is known about the characteristics of mucormycosis in Iran. In this study, we aimed to understand the distribution of this infection in Iran retrospectively and to ascertain whether the patterns of infection are associated with specific host factors or not. A total of 208 cases were included in this study occurring during 2008–2014 and were validated according to (EORTC/MSG) criteria. A rising trend as significant increase from 9.7% in 2008 to 23.7% in 2014 was observed. The majority of patients were female (51.4%) with median age of 50 and the infections were seen mostly in autumn season (39.4%). Diabetes mellitus (75.4%) was the most common underlying condition and sinus involvement (86%) was the mostly affected site of infection. Amphotericin B (AmB) was the drug of choice for the majority of cases. Sixty four isolates did not show any growth in the lab and only 21 cases were evaluated by ITS sequencing, among them; Rhizopus arrhizus var. arrhizus was the dominant species. Considering the high mortality rate of mucormycosis, early and accurate diagnosis, with the aid of molecular methods may provide accurate treatments and improve the survival rate. Therefore, increased monitoring and awareness of this life-threatening disease is critical.     

Dermoscopy and Onychomycosis: guided nail abrasion for mycological samples

Mycological examination is still the cornerstone for the diagnosis of onychomycosis for many dermatologists, but sampling technique interferes on its sensitivity and specificity. Nail abrasion may be used to reach the most proximal part of the lesion and can be easily accomplished with an electric abrasor. We suggest nail plate dermoscopy to identify the best location for localized abrasion to obtain adequate samples for mycological examination.     

Light microscopy can reveal the consumption of a mixture of psychotropic plant and fungal material in suspicious death

Light microscopical examination of plant and fungal remains in the post mortem gut may be capable of demonstrating the ingestion of unexpected natural psychotropic materials. This is demonstrated here in a case in which a 'shaman' was accused of causing the death of a young man. The deceased had participated in a ceremony which involved the drinking of ayahuasca in order to induce a psychotropic experience. Ayahuasca is an infusion of Banisteriopsis caapi (ayahuasca vine), which produces a monoamine oxidase inhibitor, and one or more additional tropical plants, generally Psychotria viridis (chacruna) which produces dimethyltryptamine (DMT). The monoamine oxidase inhibitor prevents DMT from being broken down in the gut, so enabling its passage into the bloodstream and across the blood/brain barrier. Toxicological tests for DMT demonstrated the presence of this compound in the body. The deceased was reported to be in the habit of using Psilocybe semilanceata (liberty cap). This fungus (popularly called magic mushroom) contains psilocybin which is hydrolysed in the gut to psilocin; this compound mimics a serotonin uptake inhibitor, and also invokes psychotropic experiences. Microscopical examination established that the ileum and colon contained spores of Psilocybe and, in addition, pollen of Cannabis sativa and seeds of Papaver cf. somniferum (opium poppy). Both the plant species yield psychotropic substances. Palynological and mycological analysis of containers from the deceased person's dwelling also yielded abundant trace evidence of pertinent pollen and spores. The police had requested analysis for DMT but there was no screening for other psychotropic substances. Investigators were surprised that a mixture of hallucinogenic materials had been consumed by the deceased. The charge was modified from manslaughter to possession of a ‘Class A’ drug as the deceased had been consuming psychotropic substances not administered by the 'shaman'. Where death involving drugs from plants or fungi is suspected, microscopical examination of samples from the gut can provide a rapid and effective method for assessing, in a temporal context, the presence of ingested materials that may not have been previously suspected. The example presented here also demonstrates the need for caution in interpreting toxicological results where screening for unusual compounds has been limited.     

Resistance of Candida to azoles and echinocandins worldwide

BackgroundRecently there has been an increase in Candida infections worldwide. A handful of species in the genus Candida are opportunistic pathogens and have been known to cause infections in immunocompromised or otherwise impaired hosts. These infections can be superficial, affecting the skin or mucous membrane, or invasive, which can be life-threatening. Azoles and echinocandins are antifungal drugs used globally to treat Candida infections. However, resistance to these antifungal drugs has increased in many of the Candida species, and the effects this has in the clinical setting can be seen.ObjectivesHere, we discuss the mechanisms that Candida albicans, Candida dubliniensis, Candida glabrata, Candida parapsilosis, Candida tropicalis and Candida auris are implementing to increase resistance to azoles and echinocandins, and how they are affecting clinical, or hospital, settings worldwide.SourcesDifferent studies and papers describing the mechanisms of antifungal drugs and Candida species evolution to becoming resistant to these drugs were looked at for this review.ContentWe discuss the mechanisms that azoles and echinocandins use against Candida species to treat infections, as well as the evolution of these fungi to become resistant to these drugs, and the effect this has in the clinical settings around the globe.ImplicationsIncreased resistance to azoles and echinocandins by Candida species is an increasingly serious problem in clinical settings worldwide. Understanding the mechanisms used against antifungal drugs is imperative for patient treatment.     

Allergic fungal rhinosinusitis caused by Neoscytalidium dimidiatum: A case report: Allergic fungal rhinosinusitis due to Neoscytalidium dimidiatum

Neoscytalidium dimidiatum is a rare dematiaceous fungus that was first described in 1916 as Dothiorella mangiferae. From the standpoint of epidemiology and therapy, early detection of fungal rhinosinusitis (FRS), the causative agents, and their associated risk factors can improve the therapeutic outcome and decrease the mortality rates among patients. In this study, we report a 34-year-old Iranian female patient with allergic bronchopulmonary aspergillosis (ABPA), who presented to our facility with an 8-year history of chronic fungal sinusitis, drug-resistant asthma, pneumonia, bronchitis, post-nasal discharge, nasal obstruction, nasal polyposis, and anemia. The patient was subjected to diagnostic nasal endoscopy and computed tomography (CT) scan of paranasal sinuses, as well as routine, complementary mycological, and molecular methods, which confirmed the diagnosis of allergic fungal rhinosinusitis in patients with ABPA. Neoscytalidium dimidiatum was isolated from the sinus of the patient. Results of in vitro susceptibility tests indicated that the case isolate was susceptible to amphotericin B and itraconazole at concentrations which are commonly achieved in patients receiving recommended dosages for invasive mycoses (0.25 to 0.75 mg/kg of body weight daily for amphotericin B and 100 to 400 mg daily for itraconazole) and resistant in vitro to caspofungin, voriconazole, and posaconazole. The patient was successfully treated with amphotericin B / itraconazole + postoperative oral corticosteroids (OCS). Neoscytalidium dimidiatum infection should be considered as a possible additional factor in the etiology of AFRS, especially in immunocompromised patients.     

非艾滋病患者隐球菌脑膜炎治疗与随访过程中真菌学指标分析

目的 分析非艾滋病患者隐球菌脑膜炎治疗与随访过程中真菌学指标变化规律,以指导临床治疗.方法 回顾性分析28例资料完整的非艾滋病患者隐球菌脑膜炎治疗与随访过程中的脑脊液真菌涂片,进行菌体计数、真菌培养和乳胶凝集试验.给予两性霉素B静脉滴注,联合口服氟胞嘧啶或氟康唑,疗程≥6周作为初期治疗,后给予氟康唑或(和)伊曲康唑口服≥2个月作为维持治疗,28例患者均完全治愈.统计学处理采用秩和检验.结果 治疗前脑脊液真菌涂片阳性率为92.9%,随着治疗的进行,真菌涂片的阳性率逐渐降低,菌体计数明显减少,但初期治疗结束后仍有患者真菌涂片结果为阳性.真菌培养生长所需时间逐渐延长,所有患者在治疗开始后2周真菌培养结果均转为阴性.脑脊液乳胶凝集试验阳性率为100%,治疗和随访过程中滴度小断下降,但与菌体计数降低无明显相关性.结论 隐球菌脑膜炎治疗中需要综合评价真菌学指标,对每个指标需进行具体分析.     

Development of a novel PCR assay for the identification of the black yeast, Exophiala (Wangiella) dermatitidis from adult patients with cystic fibrosis (CF)

Cystic fibrosis (CF) patients may suffer increased morbidity and mortality through colonisation, allergy and invasive infection from fungi. The black yeast, Exophiala dermatitidis (synonym Wangiella dermatitidis) has been found with increasing frequency in sputum specimens of CF patients, with reported isolation rates ranging from 1.1 to 15.7%. At present, no diagnostic PCR exists to aid with the clinical laboratory detection and identification of this organism. A novel species-specific PCR-based assay was developed for the detection of E. dermatitidis, based on employment of rDNA operons and interspacer (ITS) regions between these rDNA operons. Two novel primers, (designated ExdF & ExdR) were designed in silico with the aid of computer-aided alignment software and with the alignment of multiple species of Exophiala, as well as with other commonly described yeasts and filamentous fungi within CF sputum, including Candida, Aspergillus and Scedosporium. An amplicon of approximately 455 bp was generated, spanning the partial ITS1 region – the complete 5.8S rDNA region – partial ITS2 region, employing ExdF (forward primer [16-mer], 5′-CCG CCT ATT CAG GTC C-3′ and ExdR (reverse primer [16-mer], 5′-TCT CTC CCA CTC CCG C-3′, was employed and optimised on extracted genomic DNA from a well characterised culture of E. dermatitidis, as well as with high quality genomic DNA template from a further 16 unrelated fungi, including Candida albicans, C. dubliniensis, C. parapsilosis, C. glabrata, Scedosporium apiospermum, Penicillium sp., Aspergillus fumigatus, Aspergillus versicolor, Pichia guilliermondii, Rhodotorula sp., Trichosporon sp., Aureobasidium pullulans, Fusarium sp., Mucor hiemalis, Bionectria ochroleuca, Gibberella pulicaris. Results demonstrated that only DNA from E. dermatitidis gave an amplification product of the expected size, whilst none of the other fungi were amplifiable. Subsequent employment of this primer pair detected this yeast from mycological cultures from 2/50 (4%) adult CF patients. These two patients were the only patients who were previously shown to have a cultural history of E. dermatitidis from their sputum. E. dermatitidis is a slow-growing fungus, which usually takes up to two weeks to culture in the microbiology laboratory and therefore is slow to detect conventionally, with the risk of bacterial overgrowth from common co-habiting pan- and multiresistant bacterial pathogens from sputum, namely Pseudomonas aeruginosa and Burkholderia cepacia complex organisms, hence this species-specific PCR assay may help detect this organism from CF sputum more specifically and rapidly. Overall, employment of this novel assay may help in the understanding of the occurrence, aetiology and epidemiology of E. dermatitidis, as an emerging fungal agent in patients with CF.     

红色毛癣菌raubitschekii变种致Majocchi肉芽肿一例

目的 报道1例Majocchi肉芽肿,对其病原菌红色毛癣菌变种raubitschekii的形态学、生理学及分子学特征进行研究,并通过基因分型的方法分析其深在感染与浅表皮肤感染的关系.方法 进行临床和病理检查,真菌镜检和培养,尿素酶试验,内转录间隔区(ITS区)序列分析.对来源于该患者病变趾甲及组织的菌株及7株红色毛癣菌的rDNA非转录间隔区(NTS)串联重复亚单位1(TRS-1区)进行PCR.结果 48岁女性患者,背部、臀部、大腿出现红色丘疹、结节2个月.9个月前曾行肝移植术,甲癣病史3年,术后加重.经病理和真菌学检查,确诊为Majocchi肉芽肿.足趾甲和组织真菌培养菌落和显微镜下形态、尿素酶试验阳性,结合ITS区序列分析结果,证实致病菌为红色毛癣菌变种raubitschekii.TRS-1区扩增后显示,病变趾甲和组织来源的菌株基因型完全一致,与其余临床分离株有差异.结论 NTS区的TRS-1区显示基因多态性,病变趾甲和组织基因型完全一致,提示两者来源相同.     

Mycetomas: an epidemiological,etiological, clinical,laboratory and therapeutic review

Mycetoma is a chronic suppurative disease of the skin and subcutaneous tissue, characterized by a symptomatic triad: tumor, fistulas and grains. It can be caused by fungi (eumycetoma) and bacteria (actinomycetoma), with similar clinical features. Diagnosis is based on the clinical presentation and identification of the etiological agents in the tissue, by mycological/bacteriological, histopathological and immunohistochemical tests. It is important to specify the fungal or bacterial etiology, because the treatments are different. An approach that involves early diagnosis, the use of systemic antibiotics or antifungal agents, including surgical removal of lesions, is the basis for the treatment of these diseases. In this review, the most commonly used diagnostic methods and treatments will be discussed. Also, we will review the history of the disease through epidemiological and etiological aspects.