Branching Fungal Hyphae Research Articles

Rhinocerebral Mucormycosis Following COVID-19 Infection in Iran.

Mucormycosis (also called black fungus) is an opportunistic serious fungal infection caused by mucormycetes. It can occur in diabetes mellitus patients and other immunosuppressive conditions with recent predisposing factors such as maxillofacial surgery and corticosteroid usage. In this study, 14 patients were referred to the otorhinolaryngology or ophthalmology ward of Shafa Hospital (Kerman, Iran) with primary symptoms of nasal fullness and facial nerve dysfunction; they were admitted to the hospital to rule out the fungal infection. An endoscopic biopsy was taken from facial sinuses or orbit, and a microscopic evaluation was performed using hematoxylin and eosin (H&E) and periodic acid-Schiff (PAS) staining methods to rule out mucormycosis. In the histopathological examination, broad-based nonseptate branching fungal hyphae were found in nasal sinuses through the endoscopic biopsy. Most of the patients had diabetes mellitus with a primary symptom of facial nerve palsy; also, most of them received corticosteroids (intravenous [IV] or intramuscular [IM] injection). All patients have recently been infected with COVID-19 (less than 1 month ago). COVID-19 infection might be a predisposing factor for many opportunistic infections, such as fungal elements); thus, the physician should be aware of the dosage and duration of corticosteroid therapy to prevent the development of these infections.

P170 Life threatening hemoptysis in COVID-19 associated Pulmonary Aspergillosis (CAPA)

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMObjectiveWe report a case of large pulmonary mycotic aneurysms with massive hemorrhage as an unusual complication of CAPA which required vascular radiological interventions along with appropriate antifungal treatment.Method and ResultsA 71-year-old female patient had COVID-19 and was admitted elsewhere and she received steroids, aspirin, antibiotics, and fluconazole. Cough, dyspnea, and hemoptysis started 3 weeks later which markedly worsened over 4 days, requiring emergency hospitalization due to shock, and she received a large number of packed RBCs. The chest CT scan revealed two large nodular opacities with central breakdown and CT pulmonary angiography revealed large mycotic aneurysms within the nodular opacities (Fig. 1).The important task at the moment of presentation was pulmonary artery embolization to arrest hemoptysis; which took precedence over the diagnosis and treatment of the likely infectious process. Both aneurysms were embolized using coils and vascular plugs resulting in their obliteration.Common causes of such nodules with central necrotic cavitation and formation of pseudoaneurysms are angioinvasive molds like Aspergillus and Mucorales. In the post-COVID-19 and post steroid setting in India, invasive Mucormycosis (IM) is thought to be more common than invasive Aspergillosis (IA). A mixed infection with these molds appears to be present in about 15% of the cases. Absence of DM or hyperglycemia was somewhat against a diagnosis of Mucormycosis. TB was considered less likely due to the imaging features and Nocardia was considered less likely due to the tempo of the illness and the severity of hemoptysis.Since the clinical distinction between Aspergillosis and Mucormycosis was not possible and posaconazole can be potentially useful for both, it was chosen for treatment in preference to voriconazole. Both amphotericin B and isavuconazole were in short supply at that time. Posaconazole was used for the patient intravenously followed by gastroresistant tablets. Expectorated sputum revealed narrow, septate, acute angle branching fungal hyphae. Therapeutic drug monitoring was used later to assure an adequate drug exposure. Serum galactomannan and BDG reports were received soon after and were 2.49 ODI (Optical density Index) and >523pg/ml respectively. The mold grew in culture as shown in and was identified by morphological features and by MALDI TOF MS as Aspergillus fumigatus (Fig. 2). Sensititre MIC to posaconazole was found to be 0.12 which is considered in the susceptible range.Despite these findings indicating IA, posaconazole was not replaced by voriconazole as IM could not be ruled out as part of a mixed infection. The patient showed clinical improvement, had no further hemoptysis, serum galactomannan turned negative and CT showed obliteration of the aneurysms.ConclusionPosaconazole and isavuconazole may indeed emerge as good contemporary choices over voriconazole for IA and over amphotericin B for IM.This case adds to the clinical experience of using medical treatment with posaconazole as the sole drug and not undertaking surgery in cases such as these, due to certain extenuating circumstances.

Diphtheric aspergillosis tracheitis with gastrointestinal dissemination secondary to viral infections in a dairy calf

Diphtheric aspergillosis tracheitis is an uncommon syndrome described in human pathology, usually associated with immunosuppression in the affected individuals. Interestingly, no comparative/equivalent cases were found in domestic animals. This report describes the pathological and mycological findings associated with diphtheric aspergillosis tracheitis in an immunocompromised calf. The main pathological findings were diphtheric tracheitis and rhinitis, and necrotizing ruminitis associated with intralesional septate, acute branching fungal hyphae consistent with Aspergillus spp. Mycological culture and isolation confirmed the fungal hyphae as A. fumigatus due to characteristic features. Immunohistochemistry (IHC) assays identified intralesional antigens of bovine viral diarrhea virus (BVDV) and malignant catarrhal fever virus (MCFV) at the trachea and small intestine; IHC detected intralesional antigens of bovine alphaherpesvirus 1 (BoHV-1) only at the trachea. These findings confirmed the simultaneous occurrence of A. fumigatus with concomitant infections due to BVDV, MCFV, and BoHV-1 in this calf. Since ovine gammaherpesvirus-2 (OvHV-2) is the cause of MCF in Brail, it is likely that the intralesional MCFV antigens identified were those of OvHV-2. In this case, disseminated aspergillosis was probably associated with the undeveloped immunological status of the calf that was further impaired due to the combined immunodepressive effects of BVDV and BoHV-1 infections. Although BVDV and BoHV-1 are infectious disease pathogens frequently associated with the development of bovine respiratory disease (BRD) in feedlot and dairy cattle, the identification of intralesional OvHV-2-like antigens in several parts of the lungs suggest that this MCFV also played a role in the BRD-associated lesions identified in this calf.

Exophiala lecanii-corni keratitis presenting as a serpiginous pigmented superficial lesion: a case report

Rationale:Patients with bullous keratopathy (BK) treated by Descemet stripping automated endothelial keratoplasty (DSAEK) have a compromised cornea, due to the administration of topical steroid, postsurgical use of contact lenses, and impaired barrier function of the corneal epithelium by BK. We report a case of Exophiala lecanii-corni (E lecanii-corni) keratitis presenting as a serpiginous pigmented superficial lesion after DSAEK.Patient concerns:An 81-year-old woman who had undergone cataract surgeries, suffered from decreased vision in the left eye. She was diagnosed BK and she underwent DSAEK. Two months after DSAEK, a pigmented superficial lesion developed on the left cornea. The lesion migrated and recurred repeatedly and she was referred to our department. Best corrected vision was 20/220.Diagnoses:Light microscopy of a corneal scraping revealed branching fungal hyphae. Fungal culture showed growth of a black colony, identified as E lecanii-corni by ribosomal DNA sequencing.Interventions:We started topical treatment with 1% voriconazole and 1.5% levofloxacin. Antifungal susceptibility testing showed that the minimum inhibitory concentration of voriconazole was 0.06 μg/mL.Outcomes:The lesion scarred after treatment for 3 months, and left best corrected vision improved to 20/40.Lessons:Genus Exophiala is known as 1 of the “black molds” and a cause of chromomycosis. This is the first description of E lecanii-corni keratitis, and pigmented corneal epithelial lesions may be characteristic of this fungal genus.

Intravenous drug use causing Enterococcus Faecalis bacteraemia, mycotic pulmonary artery aneurysm and suspected Mucormycosis

Background 33 year old previously fit and well lady with a history of previous drug use presented generally unwell with shortness of breath and cough. Methods Initial investigations demonstrated marked inflammatory response with bilateral pneumonia on chest xray. She was initially treated for severe community acquired pneumonia. On day 3 of admission blood cultures isolated Enterococcus faecalis, which was later also isolated in sputum. Results Transthoracic echo demonstrated no evidence of vegetations to suggest endocarditis. Despite appropriate antibiotic switch inflammatory markers increased, and a groin abscess was suspected on clinical examination leading to CT angiogram in addition to CT thorax. Imaging demonstrated left ileofemoral DVT and a large pulmonary artery aneurysm with multiple cavitating pulmonary lesions. Following discussion with cardiothoracics the patient was transferred to a cardiothoracic centre for left lower lobectomy and lingulectomy. Histopathological perioperative samples showed branching fungal hyphae within multiple blood vessels, although 18s PCR returned as negative. The patient had a good clinical response with IV Amoxicillin and antifungal therapy - Oral Posaconazole was used as she suffered an adverse reaction to liposomal Amphotericin B. Discussion Final impression was of mycotic pulmonary artery aneurysm caused by Enterococcus faecalis with suspected mucormycosis as result of intravenous drug use. This case highlights the increased risk of mucormycosis in people who inject drugs.

Rare case of chronic pulmonary aspergillosis in emu chicks (Dromaius novaehollandiae)

Aspergillus spp. are opportunistic pathogens which cause pulmonary aspergillosis in human, animals and birds that are immunocompromised. Seven emu chicks of different ages ranging from 2 weeks to 7 weeks were presented for postmortem examination and diagnosis. Necropsy revealed granulomatous pneumonia in all the chicks. Multiple granulomas of varying sizes (1–4 mm) were also seen in the serosa of proventriculus, gizzard and kidneys. Direct microscopic examination of 10% KOH treated, lactophenol cotton blue stained smears from crushed nodules showed segments of branching fungal hyphae and conidia characteristic of aspergillus. Tease mounts wet smear preparation from the culture revealed conidiophores and conidia characteristic for Aspergillus fumigatus. Histopathologically, multifocal granulomas were seen in the lungs with central area of necrosis, numerous giant cells, mononuclear infiltration and sparse hyphae in the periphery. The frequent reports on aspergillosis in different avian species require a special attention to undertake necessary prophylactic and therapeutic measures to minimize economic losses.

Pseudo-clubbing complicated by dermatophyte onychomycosis.

1. Here, we described a case of chronic paronychia without any Candida species involved, but complicated by onychomycosis, caused by Trichophyton rubrum. A 46-year-old woman presented with a 3-year history of swelling of the right hand’s third and fourth nail folds, and a 1-year history of nails alteration. The patient stated that the dermatoses had never been treated, and there was no history of trauma, or family onchoymycosis. Dermatological examination showed that most nails of the involved fingers were lost (Fig. 1A), and the proximal and lateral nail folds were obviously swollen, and developed a pseudo-clubbing (Fig. 1B). No other nails and skin were affected. The woman was otherwise healthy. Direct microscopic examination of nail clippings revealed branching fungal hyphae. Culture growth and slide culture showed T. rubrum (Fig. 2A, B). Those of the nail folds were negative. Histopathological examination showed squamous cell hyperplasia, with parakeratosis and chronic inflammation in the dermis (Fig. 2C, D). The radiograph of fingers revealed soft tissue swelling, and no abnormality of the bones. A diagnosis of chronic paronychia, complicated by onychomycosis caused by T. rubrum, was made. Itraconazole 200 mg twice daily for one week, and topical triamcinolone acetonide acetate cream 0.05% on the nail folds twice daily for one month, were prescribed. Mycological examination after one month was negative, but there was no obvious progress of the swelling lesions, and no new nail grown out. She was disappointed, and sub

A Case of Nasal Septal Abscess Caused by Combined Bacterial and Fungal Infection in the Immunocompromised Patient

Nasal septal abscess (NSA) occurs more commonly after minor trauma and subsequent bacterial infection. However, it rarely occurs without trauma and can be associated with poor immunity. In the immunocompromised patient, NSA can occur due to fungal as well as bacterial infection; cases caused by fungal infection have been rarely reported. We experienced a case of NSA caused by combined fungal and bacterial infection without trauma in a patient with poorly-controlled diabetes mellitus. He underwent incision and drainage. Organism cultured from NSA was Staphylococcus epidermidis. Pathologic examination identified granulomatous inflammation in the septal cartilage and septate, branching fungal hy phae that had invaded the cartilage. He was treated by adequate blood glucose control and antibiotics coverage without antifungal medications. His symptom was improved despite the antifungal agent was not used. Therefore, we present this case with a brief review of the disease entity and discuss the necessity of antifungal treatment in this case. � Korean J Otorhinolaryngol-Head Neck Surg 2012;55:378-81 Key WordsZZNasal septum ㆍAbscess ㆍFungi.

Reflectance Confocal Microscopic Features of Dermatophytes, Scabies, and <emph type="ital">Demodex</emph>

R EFLECTANCE CONFOCAL MICROSCOPY PROvides in vivo imaging of the epidermis and superficial dermis at cellular level resolution and can be used to detect cutaneous fungal and parasitic infestations. Reflectance confocal microscopy of an erythematous annular scaly patch on the abdomen reveals branching fungal hyphae (Figure 1, arrows), diagnostic of tinea corporis. A linear burrow on the wrist of a pruritic patient demonstrates Sarcoptes scabiei eggs with developing mites (Figure 2, wide arrow) and feces (Figure 2, narrow arrows). Characteristic features of Demodex folliculorum, which can be seen moving in a video that is available online (http://www.archdermatol.com), are also shown in Figure 3: 8 legs (4 of which are indicated by narrow arrows) and an elongated body (wide arrow). Figure 4 reveals the native state of Demodex, with tails (arrows) protruding from a hair follicle (F). In vivo visualization of cutaneous organisms with reflectance confocal microscopy at the bedside provides an alternative to scrapings, microscopy, cultures, and biopsies.

Intranasal infusion of clotrimazole for the treatment of nasal aspergillosis in two cats

2 cats (13 and 11 years old) were evaluated to determine the cause of nasal discharge of varying duration (4 days and 5 months, respectively). Computed tomography revealed marked turbinate destruction and soft tissue densities in the nasal passages. Histologic examination of nasal specimens revealed chronic active inflammation and branching fungal hyphae consistent with Aspergillus spp. Fungal culture of nasal specimens resulted in growth of Aspergillus spp. Testing yielded negative results for antibodies against Aspergillus spp. Both cats were anesthetized and treated with a 1-hour intranasal infusion of clotrimazole. Recovery from the procedure was uncomplicated, and both cats had complete resolution of clinical signs. Little information is available on the treatment of nasal aspergillosis in cats, and the prognosis for affected animals is considered poor. The procedure for local intranasal infusion of clotrimazole in 2 cats was described here. Results and follow-up monitoring for both cats suggested that this may be a safe, effective, and durable treatment for cats with nasal aspergillosis.

Aspergillus fumigatus infection in a green parrot

Aspergillosis is a common mycotic disease of parrots which occurs as an acute infection of young parrots. The dehydrated and emaciated carcass of a 1-year-old green parrot was referred for post-mortem examination. On necropsy, disseminated variably sized granulomas were seen. At microscopic examination, they were found to contain intra-lesional septate and branching fungal hyphae. Lesions were extensive around the thoracic inlet and abdominal cavity. Aspergillus fumigatus was cultured from the visceral and thoracic granulomas. The source of exposure to the microorganism was not determined.

Disseminated Aspergillus flavus Infection in Broiler Breeder Pullets

Increased morbidity and mortality occurred in a 5-wk-old broiler breeder replacement pullet flock. The affected broiler pullet flock was housed on the first floor of a two-story confinement building. Mortality increased to 0.1%/day compared to the flock on the second floor, which had mortality levels of less than 0.01%/day. Clinical signs in the affected chickens included inactivity, decreased response to stimuli, and anorexia. No respiratory or neurologic signs were observed. On necropsy, affected pullets were dehydrated and emaciated and had disseminated variably sized single or multiple heterophilic granulomas that contained intralesional septate and branching fungal hyphae. Lesions were extensive around the base of the heart in the thoracic inlet and in the kidneys. Other affected organs included eyelid, muscle, proventriculus, ventriculus, intestine, liver, spleen, lung, and heart. Aspergillus flavus was cultured from the visceral granulomas. The source of flock exposure to the organism was not determined.

Concomitant Histopathological Findings of Allergic Fungal Sinusitis and Fungal Ball in the Same Sinus: A Rare Case Report

BACKGROUND: Allergic fungal sinusitis (AFS) and fungal ball (mycetoma) are two forms of noninvasive fungal sinusitis distinct in their clinical presentations, histopathologic features, treatment modalities, and prognoses. We report an unusual case where histopathological findings of both entities were found in the same sinus. CASE: A 63-year-old immunocompetent man with a history of allergic rhinitis, asthma and chronic rhinosinusitis (CRS) was referred to our clinic for worsening of asthma and sinonasal symptoms one year after undergoing maxillary sinus surgery. Laboratory investigations revealed peripheral eosinophilia (1300/μL) and a markedly elevated total IgE level (5469 kU/L; normal value <165 kU/L). Skin prick test was positive to A. fumigatus. The possibility of allergic bronchopulmonary aspergillosis was excluded with a normal CT of the chest. Sinus CT showed extensive mucosal changes of CRS; additionally, there was opacification associated with areas of calcification in the right maxillary sinus. At endoscopic sinus surgery, a large fungal ball embedded in thick mucus was recovered from the sinus. GMS staining showed dense branching fungal hyphae within the fungal mass and rare hyphal elements within the mucus. H&E staining revealed abundant clusters of eosinophils, consistent with allergic mucin. Mucosal biopsy demonstrated eosinophilic inflammation without fungal invasion. Cultures were negative. Systemic and topical steroids were initiated to reduce the eosinophilic inflammatory response and prevent disease recurrence. CONCLUSIONS: This is an unusual case of AFS and fungal ball coexistence in the same sinus, illustrating the importance of considering AFS as a diagnostic possibility in the presence of chronic rhinosinusitis associated with IgE-mediated hypersensitivity to fungi.

Allergic fungal sinusitis presenting as a paranasal sinus tumor.

We present a case of allergic fungal sinusitis (AFB) in a 20-year old man with few months' history of bilateral nasal obstruction and discharge with unilateral proptosis that underwent maxillary antrostomy due to the mass in paranasal sinuses. Histological examination of tissue showed branching fungal hyphae interspersed with allergic mucin without fungal invasion to soft tissue. The patient received local steroid for 4 months and had no problem during follow up. Fungal culture was performed and Bipolaris fungus grew. Although most dematiaceous fungal infections occur in immunocompetent patients, the incorrect diagnosis and insufficient treatment may be life threatening.

Chronic Invasive Fungal Sinusitis: A Report of Two Atypical Cases

The purpose of this article is to describe a chronic variant of invasive fungal sinusitis (IFS) and discuss its management. This is a retrospective review of two cases of IFS that were characterized by atypical clinical courses. Patient 1 was a 75-year-old man with noninsulin-dependent diabetes mellitus who came to us with a 5-month history of headache. Computed tomography detected an opacified left sphenoid sinus. After the man failed to respond to medical therapy, he underwent a left endoscopic sphenoidotomy. Pathologic examination revealed that septate, branching fungal hyphae had invaded the soft tissues. The patient was started on oral itraconazole, but later switched to intravenous amphotericin B in response to intracranial extension. The man's disease stabilized, but he died a little more than 1 year later of unrelated causes. Patient 2 was an otherwise healthy 41-year-old woman who came to us with nasal congestion and unilateral nasal polyps. She underwent endoscopic sinus surgery. Pathologic examination identified granulomatous sinusitis and septate, branching fungal hyphae that had invaded the soft tissue of the middle turbinate. The patient was not treated with systemic antifungal medications because of the localized nature of the fungal invasion and the lack of bone invasion or erosion. She has now been symptom-free for 5 years. These two cases demonstrate that IFS can appear in a chronic variant form that is characterized by an indolent course and histologic evidence of tissue invasion by fungal hyphae. The type of treatment is dependent on the extent of the disease on initial examination and the rapidity of its progression.

Mycotic Rhinitis in an Ostrich

A 2-year-old female ostrich had become gradually emaciated over a 4-month period and subsequently died. Gross necropsy revealed a granulomatous mass filling the right nasal passageways. Microscopically, the mass contained numerous thin, regular-diameter, septate, branching fungal hyphae consistent with Aspergillus sp. and foreign plant material. This appears to be the first report of a mycotic granuloma limited to the nasal cavities of an ostrich or any other ratite species.