Inhalation Of Spores Research Articles

MYCOSES OF MUSTELIDS OF CELL CONTENT

The focus of attention of authoritative international organizations, such as the World Health Organization, the Food and Agriculture United Nations, is the problem of contamination by fungal microflora of feed and the formation of secondary metabolites (mycotoxins) and a number of micromycetes. Contaminant fungi are mainly represented by saprophytic species with disease-causing potential. Entering the body of an animal, fungi can cause invasive lesions of the gastrointestinal tract (mucoromycosis), infection by inhalation of fungal spores, followed by the development of respiratory mycoses (aspergillosis). Almost all types of molds are capable of synthesizing mycotoxins. Some types of fungi (Penicillium) form antibiotics as secondary metabolites, which, when ingested, can disrupt the composition of the microflora of the gastrointestinal tract. The article presents the results of studies on the identification of mycoses in mustelids of cell content. To determine the species composition of pathogenic fungi, most often found in mustelids in fur farms of the Russian Federation, microbiological studies were carried out using selective culture media and a MicroTax microbiological analyzer. As a result of laboratory research, it was found that among the isolated material from the internal organs, pathogenic fungi of the genera Fusarium, Aspergillus, Mucor, Candida are most often found. Microbiological examination of animal feed (porridge, grain grinding, fish feed) revealed identical pathogens. As a result of setting a bioassay on rabbits and white mice, the pathogenicity of the isolated fungi was determined. A laboratory study was carried out to study the effect of the isolated mushrooms and their metabolic products on the weasel organism.

RADICAL TREATMENT FOR BLASTOMYCOSIS FOLLOWING FAILED LIPOSOMAL AMPHOTERICIN

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary blastomycosis is a respiratory disease that is caused by the fungus Blastomyces, most commonly through inhalation of the fungal spores. Infected individuals typically show symptoms 3 weeks to 3 months after inhalation of these spores. About 50% of patients with pulmonary blastomycosis are asymptomatic. Individuals with severe blastomycosis are initially treated with intravenous antifungal therapy with Amphotericin followed by long-term itraconazole maintenance therapy. CASE PRESENTATION: We present the case of an immunocompetent young male who was diagnosed with pulmonary Blastomyces dermatitidis and had poor clinical response to 10 days of liposomal Amphotericin B (L-AmB). Due to persistent hypoxia and hypoxemia, the patient was endotracheally intubated and extracorporeal membrane oxygenation (ECMO) was initiated. Due to the poor response to L-AmB, L-AmB was discontinued in favor of continuous infusion of amphotericin B deoxycholate (AmB-d). Additionally, the patient was started on a short course of corticosteroids. With the combination of these treatments, the patient had significant clinical improvement. The patient was taken off ECMO on day 9 and extubated on day 12 after the initiation of AmB-d. DISCUSSION: Literature review yielded limited information regarding treating blastomycosis with a continuous AmB-d infusion. To our knowledge, this is the third case reported in the literature of the use of continuous AmB-d infusion for the treatment of severe blastomycosis. ARDS due to blastomycosis has a mortality of up to 80% with the standard of treatment in such severe cases being liposomal amphotericin. Given that ECMO and AmB-d infusion were started concurrently, it is unclear if the significant improvement was due to the decrease in burden on the respiratory system by ECMO or due to AmB-d infusion demonstrating higher effectiveness compared to liposomal amphotericin B, or a combination of both. A case reported by Branick, K et al. discusses a patient on ECMO treated with L-AmB without improvement until AmB-d continuous infusion was started. Even though they attributed the treatment failure to clogging of the ECMO circuit by L-AmB, their belief was that ECMO is not an effective means to treat Blastomycosis and therefore, believed that the patient improvement was solely due to AmB-d infusion. CONCLUSIONS: While L-AmB is considered first line treatment for blastomycosis, the mortality remains high in those with ARDS associated with blastomycosis. This case demonstrates the importance of considering AmB-d in patients with severe blastomycosis who may have poor response to L-AmB. ECMO and steroids were also included in the patient's treatment plan which may have contributed to the patient's improvement. In a disease process with such high mortality rates, the need for continued evaluation of treatment options is crucial given the limited treatment options currently available. REFERENCE #1: Branick K, Taylor MJ, Trump MW, Wall GC. Apparent interference with extracorporeal membrane oxygenation by liposomal amphotericin B in a patient with disseminated blastomycosis receiving continuous renal replacement therapy. Am J Health Syst Pharm. 2019;76(11):810-813. REFERENCE #2: Meyer KC, McManus EJ, Maki DG. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome. N Engl J Med. 1993;329(17):1231-1236. REFERENCE #3: Lahm T, Neese S, Thornburg AT, Ober MD, Sarosi GA, Hage CA. Corticosteroids for blastomycosis-induced ARDS: a report of two patients and review of the literature. Chest. 2008;133(6):1478-1480. DISCLOSURES: No relevant relationships by Christopher Chew, source=Web Response No relevant relationships by Henry Ogbuagu, source=Web Response No relevant relationships by Dhaval Patel, source=Web Response No relevant relationships by Nikhilesh Thapa, source=Web Response No relevant relationships by Merin Varghese, source=Web Response

UNEXPECTED DIAGNOSIS IN A 49-YEAR-OLD FEMALE WITH HEMOPTYSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hemoptysis is a common but potentially life-threatening symptom requiring urgent evaluation. The most common causes include respiratory tract infections and malignancy. We present a case of an uncommon infectious etiology of hemoptysis in an immunocompetent female. CASE PRESENTATION: A 49-year-old female presented with cough and hemoptysis. She is a never smoker, lives in Southern New Jersey, and keeps dogs, chickens and goats. She had no significant travel history. Chest CTA demonstrated an irregular 2.5 cm right lower lobe nodule. Biopsy of the lung nodule revealed peribronchial and alveolar tissue with necrotizing granulomatous inflammation. No definitive fungi or mycobacteria were identified on tissue staining. An infection could not be ruled out due to the low sensitivity of the tests. Tissue culture was not initially completed due to high suspicion for malignancy. She had persistent hemoptysis mainly with exertion. Bronchoscopy was performed with bronchoalveolar lavage revealing a friable and edematous mucosa with purulent secretions in the right lower lobe. Bronchial washing sample demonstrated black fragmented tissue. Fungal culture revealed Rhizopus species. She was placed on posaconazole and at follow-up has had an improvement in overall symptoms, although she still endorses fatigue. DISCUSSION: Mucormycosis is an opportunistic fungal infection with a high mortality rate caused by environmental molds, often Rhizopus species. It has an incidence of 3.0 cases per million populations in the U.S. There has been a rise in its incidence globally, perhaps due to an increase in susceptible populations. Risk factors include diabetes mellitus, malignancies (hematological and solid organ tumor), transplant recipients (hematopoietic stem cell and solid organ transplants), corticosteroid therapy, and neutropenia. Our index patient had none of these risk factors except for repeated environmental exposure to animal waste and thus persistent inhalation of fungal spores. Clinical forms of the infection include rhino-cerebral, cutaneous, pulmonary, and disseminated disease. Diagnosis is made through a histopathological finding of characteristic hyphae with tissue necrosis and angioinvasion or culture of a specimen from the infection site. Recommended therapy includes a combination of surgical intervention and antifungal treatment with amphotericin B. Posaconazole is an alternative antifungal with a better safety profile used most often as a step-down or salvage therapy from amphotericin B. CONCLUSIONS: Pulmonary mucormycosis has high morbidity and mortality. It is important to keep broad differential diagnoses and obtain a thorough history during the initial evaluation of hemoptysis. REFERENCE #1: Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of Hemoptysis. Dtsch Arztebl Int. 2017;114(21):371-381. REFERENCE #2: Prakash H, Chakrabarti A. Global Epidemiology of Mucormycosis. J Fungi (Basel). 2019;5(1):26. Published 2019 Mar 21. doi:10.3390/jof5010026 REFERENCE #3: Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh T, Kontoyiannis D. Epidemiology and Clinical Manifestations of Mucormycosis, Clinical Infectious Diseases, 2012. 54(1): S23–S34 DISCLOSURES: No relevant relationships by Kaitlyn Dalsey, source=Web Response No relevant relationships by Lisa Ezegbu, source=Web Response no disclosure on file for Frances Loftus; no disclosure on file for Manish Trivedi

INTRAPLEURAL AMPHOTERICIN B INSTILLATION: A NOVEL APPROACH TO THE TREATMENT OF CHRONIC PULMONARY COCCIDIOIDOMYCOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coccidioidomycosis is transmitted by inhalation of fungal spores commonly found in southwestern border of United States and South America. Most primary coccidioidomycosis cases are asymptomatic and do not require treatment. Symptomatic progressive coccidioidomycosis affect people with certain risk factors: ethnic origin, advanced age, pregnancy, and immunosuppressive state. Most cases are effectively treated with oral triazoles. Intravenous (IV) amphotericin B (AMB) is reserved for severe cases. Although intrapleural instillation of AMB has been reported in cases for aspergillus empyema, it has not been reported for other diseases (1). We are reporting the first known case of successful novel use of intrapleural instillation of amphotericin B in the treatment of chronic progressive pulmonary coccidioidomycosis. CASE PRESENTATION: A 48-year-old Hawaiian man with diabetes mellitus type 2 presented with 10 days of epigastric pain, anorexia, constipation, chills, progressive shortness of breath, and low-grade fever. He had a 9-month nonproductive cough after returning from Las Vegas. He was admitted to another facility where he was diagnosed with cryptogenic organizing pneumonia and treated with moderate dose prednisone for over 6 months. Initial chest x-ray here revealed a large left pneumothorax. Chest tube insertion did not provide significant improvement. Subsequent chest computerized tomography (CT) revealed a large hydropneumothorax with lingular and left lung base consolidation. Transbronchial biopsy showed coccidioides. After 7 days of hospitalization, patient was discharged home with fluconazole. He was readmitted 2 weeks later due to recurrence of same set of symptoms. Chest CT scan now revealed progression of multifocal necrotizing pneumonia. Based on continued deterioration despite IV AMB, there was a high suspicion of persisting intrapleural infection with coccidioides. A left pneumonectomy with placement of a special drainage catheter for intrapleural instillation was performed, in addition to continued IV AMB. He tolerated 7 days of intrapleural AMB well and discharged home 9 days afterward with continued fluconazole. One year later he was able to resume all normal activities. DISCUSSION: Our patient developed progressive coccidioidomycosis due to uncontrolled diabetes mellitus from prednisone prolonged use. He has progressive pneumonia, pulmonary nodules and cavities, fever, cough, chills, hemoptysis, abdominal pain, anorexia, weight loss, and weakness. Due to the many adverse reactions of AMB, it is generally reserved for severe cases; in our case, the addition of intrapleural instillation was successful in conjunction with his pneumonectomy and IV antifungal therapy. CONCLUSIONS: This is the first known reported case of intrapleural amphotericin B instillation, in combination with conventional therapy, in the successful treatment of chronic progressive coccidioidomycosis. REFERENCE #1: Almuhareb, A., & Habib, Z. (2018). Management of Aspergillus Pleural Empyema with Combined Systemic and Intrapleural Antifungal Therapy in a Pediatric Patient: Case Report. Journal of Infection and Public Health, 11(2), 280-282. DISCLOSURES: No relevant relationships by Angelica Guzman Paz, source=Web Response No relevant relationships by Takkin Lo, source=Web Response

AN INCEDENTAL NODULE: ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Repeated inhalation of aspergillus spores can trigger a hypersensitivity immune reaction in susceptible hosts, producing allergic bronchopulmonary aspergilloses (ABPA) with a range of findings. Patients may be asymptomatic, or have symptoms including fever, dry or productive cough, dyspnea, chest pain, eosinophilia, radiographic infiltrates, as well as extensive lung disease and respiratory failure. Here we present a case of APBA discovered incidentally as a pulmonary nodule. CASE PRESENTATION: A 54-year-old female with asthma, hepatitis C and cirrhosis presented with melena. Variceal banding, transfusions, and supportive care stabilized her condition. Admission chest x-ray demonstrated a left pulmonary nodule. CT chest revealed a 2.9 cm left upper pulmonary nodule with tree-in-bud appearance and mucoid impaction. The patient had no respiratory signs or symptoms. The patient was discharged with nebulizers and pulmonary follow up. Outpatient bloodwork showed elevated absolute eosinophils. Pulmonary function tests demonstrated obstructive defect with reduced DLCO. Repeat CT chest confirmed diffuse left upper lobe tree-in-bud opacities and mucus plugging, with new bronchiectasis and wall thickening in the right middle, anterior right lower, and left lower lobes, suggestive of atypical infection. Although still asymptomatic, airway clearance and further workup were initiated. A bronchoscopy with lavage and endobronchial ultrasound with transbronchial needle aspiration demonstrated abundant eosinophils on biopsy with positive universal PCR for aspergillus. Gram stain, AFB and fungal cultures were negative. Preliminary diagnosis of ABPA was made. For the first time, the patient noted symptoms of cough, headache and back pain. Confirmatory testing showed aspergillus precipitans IgG and elevated total IgE. Negative aspergillus galactomannan antigen, and negative coccidioides, blastomyces dermatitidis, and histoplasma antibodies clarified the ABPA diagnosis. Prednisone and itraconazole were arranged alongside CT chest in 3-4 months. DISCUSSION: This patient with cirrhosis and asthma had decreased lung function, elevated serum IgE, aspergillus fumigatus precipitans, progressive CT infiltrates, bronchiectasis and mucous plugging. These findings strongly suggest ABPA. Although initially without respiratory symptoms, given irreversible airway dilation, therapy was initiated to reduce inflammation and prevent/slow progression into fibrotic or cavitary disease. CONCLUSIONS: In patients with asthma and recurrent infiltrates on chest imaging, one should consider the diagnosis of ABPA, even if asymptomatic. Early identification and treatment can reduce symptoms, slow progression or prevent permanent airway damage. Azoles reduce fungal burden, steroids suppress immune hyperreactivity, and radiologic/serum total IgE surveillance assist monitoring. REFERENCE #1: Shah A, Panjabi C. Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity. Allergy Asthma Immunol Res. 2016 Jul;8(4):282-97. doi: 10.4168/aair.2016.8.4.282. PMID: 27126721; PMCID: PMC4853505. REFERENCE #2: Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax. 2015 Mar;70(3):270-7. doi: 10.1136/thoraxjnl-2014-206291. Epub 2014 Oct 29. PMID: 25354514. REFERENCE #3: Agarwal R, Sehgal IS, Dhooria S, Aggarwal AN. Developments in the diagnosis and treatment of allergic bronchopulmonary aspergillosis. Expert Rev Respir Med. 2016 Dec;10(12):1317-1334. doi: 10.1080/17476348.2016.1249853. Epub 2016 Nov 7. PMID: 27744712. DISCLOSURES: No relevant relationships by Sami Bashour, source=Web Response No relevant relationships by Philip Lavere, source=Web Response no disclosure on file for Dipaben Modi

An Overview of an Invasive Fungal Infection In Covid-19: Mucormycosis

Mucormycosis is an invasive fungal infection of zygomycetes class, comprised the orders of entomophtherales and mucorales which is common infection in immuno compromised patients, especially in stem cell transplantation, hematological malignancy and diabetes mellitus. It is the third invasive fungal infection after aspergillosis and candidiasis both strain belong the class of zygomycetes. Mucormycosis generally transmitted in humans by the inoculation and inhalation of spores in mucous membrane as well as skin. After the deadly outbreak of corona virus, this infection has taken a different form in those patients who suffer from the covid-19 which is categorized as a post covid-19 disease. Aim of this review to highlight the recent awareness about invasive fungal treatment.

Antifungal and antitoxin effects of propolis and its nanoemulsion formulation against Aspergillus flavus isolated from human sputum and milk powder samples.

Background and Aim:Aspergillus flavus causes human and animal diseases through either inhalation of fungal spores or ingestion of mycotoxins as aflatoxins produced in human and animal feed as secondary metabolites. This study was aimed to detect the incidence of A. flavus and its aflatoxins in human sputum and milk powder samples and explore the efficacy of pure propolis (PP) and propolis nanoemulsion (PNE) as natural decontaminants against fungal growth and its released aflatoxins.Materials and Methods:A. flavus was isolated by mycological culture and identified macroscopically and microscopically. Coconut agar medium and thin-layer chromatography (TLC) were used to qualitatively detect aflatoxins in the isolated strains. Toxins were extracted from toxigenic strains by the fast extraction technique. The quantitative detection of toxin types was explored by high-performance liquid chromatography (HPLC). PNE was prepared by a novel method using natural components and characterized by Fourier-transform infrared spectroscopy, Zetasizer, and transmission electron microscopy. The effects of PP and PNE on A. flavus growth and its toxin were determined by the well-diffusion method and HPLC.Results:The mycological culture showed that 30.9% and 29.2% of sputum and milk powder samples were positive for A. flavus, respectively. TLC confirmed the production of 61.8% and 63.2% aflatoxin by the isolated strains in sputum and milk powder, respectively. PP and PNE showed antifungal activity on A. flavus growth with mean±standard error (SE) inhibition zones of 27.55±3.98 and 39.133±5.32 mm, respectively. HPLC revealed positive contamination of toxin extracts with AFB1, AFB2, and AFG2 at 0.57±0.026, 0.28±0.043, and 0.1±0.05 mg/L, respectively. After treatment with PP and PNE, a significant decrease in AFB1, AFB2, and AFG2 concentrations was observed.Conclusion:This study suggested using propolis and its nanoformulation as antifungal and antitoxins in human medicine and the food industry to increase the food safety level and stop food spoilage.

Facial Ulcer: A Harbinger of Post-COVID-19 Mucormycosis, a Case Report

: Facial ulcers may be the manifestation of a wide variety of disorders with infective, inflammatory, granulomatous, or malignant etiopathogenesis, leading to challenges in differential diagnosis and management. Mucormycosis is an angio-invasive, rapidly spreading, and potentially fatal fungal infection beginning from the nose and paranasal sinuses after the inhalation of fungal spores, manifesting with cutaneous necrotic eschar. The rhinomaxillary region is the commonest site involved, particularly in immunocompromised individuals. Mucormycosis incidence in people with coronavirus disease 2019 (COVID-19) is on the rise, especially in India during the second wave. Diabetes mellitus is an independent risk factor for severe COVID-19 infection, as well as for mucormycosis. We report an elderly gentleman with uncontrolled diabetes, treated for the COVID-19 infection, who presented with an ulcer over the left nasal ala. This case report highlights the importance of high-index suspicion and prompt and aggressive multidisciplinary management of mucormycosis, as a life-saving measure.

Novel Mouse Models of Fungal Asthma.

Alternaria alternata is a ubiquitous fungus and a major allergen associated with the development of asthma. Inhalation of intact spores is the primary cause of human exposure to fungal allergen. However, allergen-rich cultured fungal filtrates are oftentimes used in the current models of fungal sensitization that do not fully reflect real-life exposures. Thus, establishing novel spore exposure models is imperative. In this study, we established novel fungal exposure models of both adult and neonate to live spores. We examined pathophysiological changes in the spore models as compared to the non-exposure controls and also to the conventional filtrate models. While both Alternaria filtrate- and spore-exposed adult BALB/c mice developed elevated airway hyperresponsiveness (AHR), filtrates induced a greater IgE mediated response and higher broncholavage eosinophils than spores. In contrast, the mice exposed to Alternaria spores had higher numbers of neutrophils. Both exposures induced comparable levels of lung tissue inflammation and mucous cell metaplasia (MCM). In the neonatal model, exposure to Alternaria spores resulted in a significant increase of AHR in both adult and neonatal mice. Increased levels of IgE in both neonatal and adult mice exposed to spores was associated with increased eosinophilia in the treatment groups. Adult demonstrated increased numbers of lymphocytes that was paralleled by increased IgG1 production. Both adults and neonates demonstrated similarly increased eosinophilia, IgE, tissue inflammation and MCM.

Mucormycosis: A Surge in Mucorales Fungal Infection in Post – Covid Patients in Indian States and Insight into Known and Unknown Factors

Mucormycosis is a rare opportunistic fungal infection in human caused by fungi belonging to the fungal order Mucorales and the family Mucoraceae which are now classified in the (new) phylum Glomeromycota (earlier Zygomycota), class Glomeromycetes (earlier Zygomycetes), subphylum Mucoromycotina, order Mucorales. The Mucorales comprise 55 genera with 261 species. Out of these, 39 species belonging to 12 genera viz. Actinomucor, Apophysomyces, Cokeromyces, Cunninghamella, Lichtheimia, Mycotypha, Mucor, Rhizomucor, Rhizopus, Saksenaea, Syncephalastrum, and Thamnostylum have been reported to be involved in human infections of mucormycosis. However, their prevalence niches in the states or countries is not yet well studied and documented. Clinical presentations of mucormycosis primarly include rhinocerebral, pulmonary, and cutaneous (superficial) and less frequently, gastrointestinal, disseminated, and miscellaneous forms. Pathophysiology involves inhalation of spores through the nose or mouth or even through a skin laceration. The fungus may then spread to the paranasal sinuses and consequently to the orbit, meninges, and brain by direct extension. The unchecked infection results in surgical debridement and even can be fatal. Individuals with compromised cellular and humoral defense mechanisms, diabetic patients, patients on steroid medication, and persons who had major surgeries are prone to mucormycosis infection. A surge in the cases of mucormycosis in post covid patients in the second wave of covid infection were observed in India where the mucormycosis cases increased upto 150 % in 3 weeks (May 25th to June 20th 2021) with 6.7 % of deaths.The number of cases with mortality % varied in different states of the country. The percentage of surgical debridement of eye due to mucormucosis in Nagpur district of Maharashtra state is reported for 78% patients. Even a six month old child’s death is reported due to mucormycosis in Ahmadnagar district of the state indicating the gravity of the disease. However, these mucormycosis infection is generalized as infection due to black fungus, white fungus, yellow fungus, or green fungus without naming the etiological species responsible in different parts of the country. To control this mucormycosis infection, the antifungal drug Amphotericin B is used. However, the development of resistance to this drug is already reported in some of the species causing mucormycosis. Furthermore, different species of mucormycosis fungus is reported to vary in their sensitivity to this drug. Moreover, the Amphotericin B deoxycholate is also reported to cause nephrotoxicity in some of the patients. The mucorales species are characterized by high level resistance to some of the currently available antifungal drugs. Antifungal specificity within the group may be species specific, therefore knowledge of species prevailed in the particularly area of the country is atmost important in the management strategies of the mucormycosis. Amphotericin B, Posaconazole and Isavuconazole are currently the most active drug against mucorales, however, their activity remains sub-optimal and new therapeutic strategies are needed Various known and unknown factors supportive for mucormycosis are summerised in this paper with an emphasis to have a better understanding on these for the prevention of the infections. Handling of issues like monitoring of air quality data for mucorales in metro cities and in hospitals and their displays at fortnight intervals will be worth to forecast the mucormycosis infections and management of etiological agent. Such forecast will prove a milestone for immunocompromised patients to avoid such places and thereby mucormycosis infection. The governments should make a policy for municipal corporations and hospitals to monitor and display the air quality data for mucormycosis fungi. WHO also should look and consider such important policy issues of monitoring air quality data for mucorales to deal with the emerging trends of Mucormycosis.

Abdominal Hernia in a Common Mynah (Acridotheres tristis) Associated with Hepatic Lipidosis and Concurrent with Respiratory Aspergillosis

Background: Hepatic lipidosis and hernia, are problems in pet birds which can occur due to different causes. Aspergillosis, is also an important disease of pet birds, usually caused by inhalation of conidia or spores of Genus Aspergillus. This article is a case report of simultaneous occurrence of hepatic lipidosis, hernia, and aspergillosis in a common mynah, in Iran.Materials and Methods: A 7-year-old male common mynah was presented with severe signs of dyspnea, history of anorexia, feeding with high energy diet and traveling to northern parts of Iran. Unfortunately, before any medical interventions, the bird died. Necropsy was done to diagnose cause of death. Tissue samples of abdominal viscera, lungs and air sacs and were fixed in 10% formalin and stained with hematoxylin and eosin. Serial sections were also stained by PAS to highlight any fungal hyphae. Cultures from the liver and bone marrow were performed on Blood and MacConkey agars.Results & Conclusions: In carcass external examination, abdominal swelling, hernia and yellow discoloration under skin were obvious. At necropsy, liver was enlarged with yellowish discoloration. There was also high amount of fat around abdominal viscera. Microscopically, fatty change, hepatocellular necrosis and hemorrhages were seen in liver. There were also vegetative forms of Aspergillus on lung’s parenchyma and air sacs. No bacterial growth was observed. Pet birds are usually restricted to cage by minimal contact with other birds, thus diseases related to management are common among these birds, so keeping in suitable condition with appropriate balanced diet is important for their health.

COVID-19-associated rhino-orbital mucormycosis (CAROM)\u2014a case report

BackgroundThere has been a rapid rise in the number of COVID-19-associated rhino-orbital mucormycosis (CAROM) cases especially in South Asian countries, to an extent that it has been considered an epidemic among the COVID-19 patients in India. As of May 13, 2021, 101 CAROM cases have been reported, of which 82 cases were from India and 19 from the rest of the world. On the other hand, pulmonary mucormycosis associated with COVID-19 has a much lesser reported incidence of only 7% of the total COVID-19-associated mucormycosis cases (Singh AK, Singh R, Joshi SR, Misra A, Diab Metab Syndr: Clin Res Rev, 2021). This case report attempts to familiarize the health care professionals and radiologists with the imaging findings that should alarm for follow-up and treatment in the lines of CAROM.Case presentationRhino-orbital mucormycosis (ROM) is a manifestation of mucormycosis that is thought to be acquired by inhalation of fungal spores into the paranasal sinuses. Here, we describe a 55-year-old male, post COVID-19 status with long standing diabetes who received steroids and ventilator therapy for the management of the viral infection. Post discharge from the COVID-19 isolation ICU, the patient complained of grayish discharge from the right nostril and was readmitted to the hospital for the nasal discharge. After thorough radiological and pathological investigation, the patient was diagnosed with CAROM and managed.ConclusionUncontrolled diabetes and imprudent use of steroids are both contributing factors in the increased number of CAROM cases. Our report emphasizes on the radiological aspect of CAROM and reinforces the importance of follow-up imaging in post COVID-19 infection cases with a strong suspicion of opportunistic infections.

COVID-19–associated central nervous system mucormycosis

Mucormycosis is a life-threatening infection caused by fungi of the order Mucorales. Central nervous system (CNS) mucormycosis is usually an extension of the infection from the sinuses to the eyes and brain. CNS mucormycosis arises from an adjacent paranasal sinus infection (rhinocerebral) by direct extension or hematogenous dissemination from the lungs, but isolated CNS mucormycosis is a rare presentation. During an episode of fungemia, seeding may occur in brain tissue, leading to this infection. The most common clinical presentation of mucormycosis is rhino-orbital-cerebral infection, which is presumed to start with inhalation of spores into the paranasal sinuses of a susceptible host. In this article, we emphasize on the COVID-19–associated mucormycosis, particularly the involvement of CNS.

The need for environmental surveillance to understand the ecology, epidemiology and impact of Cryptococcus infection in Africa.

ABSTRACTOur understanding of the pathogenic yeasts Cryptococcus neoformans and Cryptococcus gattii has been greatly enhanced by use of genome sequencing technologies. Found ubiquitously as saprotrophs in the environment, inhalation of infectious spores from these pathogens can lead to the disease cryptococcosis. Individuals with compromised immune systems are at particular risk, most notably those living with HIV/AIDS. Genome sequencing in combination with laboratory and clinical studies has revealed diverse lineages with important differences in their observed frequency, virulence and clinical outcomes. However, to date, genomic analyses have focused primarily on clinical isolates that represent only a subset of the diversity in the environment. Enhanced genomic surveillance of these yeasts in their native environments is needed in order to understand their ecology, biology and evolution and how these influence the epidemiology and pathophysiology of clinical disease. This is particularly relevant on the African continent from where global cryptococcal diversity may have originated, yet where environmental sampling and sequencing has been sparse despite harbouring the largest population at risk from cryptococcosis. Here, we review what scientifically and clinically relevant insights have been provided by analysis of environmental Cryptococcus isolates to date and argue that with further sampling, particularly in Africa, many more important discoveries await.

Case series of rhinocerebral mucormycosis second wave covid 2021: Mortality or survival real factors

Background: Rhinocerebral mucormycosis is a complex and fatal infection typically affecting diabetic and/ or immunocompromised patients, but recently seen in large numbers during the second wave of corona infection. This dreadly infection was found typically in patients who were administered steroids and higher antibiotics. Usually, these kinds of manifestations are noticed due to inhalation of fungal spores. Fungi constitute a kingdom of ubiquitous eukaryotic organisms that actively replicate during decomposition and recycling of matter in the natural environment. About 50000 fungal species, of which only 400 are actually pathogenic for humans. Approximately a dozen of which are responsible for 90% of frequently encountered fungal infections. Material and methods: Survival rate of patients is moderately high 95% and Mortality rate is only 5% in our series due to early diagnosis and treatment with aggressive sugar control, repeated debridement antifungal therapy and regular follow up with MRI PNS Contrast. Results: In this case series, 156 cases with rhinocerebral mucormycosis were presented. The etiologic agents and other survival and Mortality factors of mucormycosis in 156 Patients were isolated and identified by sequence analysis and data were registered and presented. Conclusion: In patients with mucormycosis, early detection, surgical excision and appropriate debridement, suitable antifungal therapy, MRI Contrast and control of risk factors like, Covid patient on steroids and higher antibiotics, diabetes mellitus are the main parameters of successful management of this lethal infection.

Isolation and Characterization of Nocardiae Associated with Foaming Coastal Marine Waters.

Nocardiosis is an infectious disease caused by Nocardia species that occurs worldwide, albeit more prevalently in tropical/subtropical regions. It can appear as either acute, subacute or as a chronic infection mostly with those with a compromised/weakened immune system. Inhalation of spores and or mycelium fragments is the main transmission route for developing pulmonary nocardiosis. In contrast, cutaneous nocardiosis usually occurs via direct contact. In the subtropical region of the Sunshine Coast in Australia foaming events with thick and persistent and orange-brown color foam have been observed during summer seasons in the near shore marine environments. This study reports the existence of nocardiae in these near shore marine environments by the use of a novel isolation method which used the gas requirements of nocardiae as a selective battery. A total of 32 nocardiae were isolated with the use of this novel method and subsequently conducted molecular identification methods confirmed that the isolates belonged to the genus Nocardia. Twenty-one isolates out of the 32 were closely related to N. nova strains MGA115 and one was related to CBU 09/875, in addition when compared with human pathogenic nocardiae twenty of the isolates were found to be related to N. nova strain JCM 6044. Isolates displayed varied resistance against some of the antibiotics tested when interpretation threshold recommended the Comite de L’Antibiogramme de la Societe Francaise de Microbiologie were used. The highest level of resistance against cefotaxime (n = 27) and ceftriaxone (n = 24). Some of the isolates (n = 6) that displayed resistance to selected antibiotics also possessed potential human pathogenic characteristics such as adherence and translocation through human long epithelial cells as well as displaying phage resistance (n = 26). They might thus present a potential public health risk if frequently encountered through exposure to aerosols generated by the foam as well as direct contact through a wound. Preventative measures to control the growth of nocardiae in such environments such as the control of pollutants, might prevent potential infections that might be caused by these bacteria in humans as well as in marine animals.

Disseminated coccidioidomycosis in a patient with juvenile idiopathic arthritis receiving infliximab

BackgroundCoccidioides immitis is a dimorphic fungus endemic to the arid climates of the Southwest United States, Mexico and parts of Central and South America. Human infection occurs through inhalation of spores with less than half of exposures progressing to a symptomatic state that primarily consists of pulmonary manifestations. Disseminated coccidioidomycosis is exceedingly rare, occurring in fewer than 1 % of symptomatic infections. Through hematogenous spread, the fungus can infect most organ systems and may be fatal without systemic antifungal treatment. Individuals with impaired cell-mediated immunity either from primary immunodeficiency disorders or secondary to immunosuppression with medications such as tumor necrosis factor alpha (TNF-α) inhibitors have increased risk of disseminated coccidioidomycosis and previous cases of coccidioidomycosis have been reported with biologic therapy.Case presentationWe present a case of disseminated coccidioidomycosis in a 16-year-old female with polyarticular juvenile idiopathic arthritis (JIA) being treated with prednisone, methotrexate, and infliximab. The patient presented with symptoms of meningeal irritation, bilateral choroidal lesions, and necrotizing peripheral pneumonia. Her infection was thought to be a reactivation of coccidioidomycosis given her history of resolved pneumonia that occurred after traveling to Arizona, New Mexico, and El Paso one year prior to presentation. Following diagnosis, she improved with discontinuation of her immunosuppressive medications and two weeks of intravenous amphotericin B and fluconazole with plans for lifetime treatment with fluconazole while immunosuppressed. Due to worsening arthritis, she will begin tofacitinib and continue close monitoring of chest x-rays and coccidioides antibody.ConclusionsPatients undergoing immunosuppressive therapy for rheumatological conditions are at increased risk of disseminated coccidioidomycosis and should be evaluated with high suspicion when presenting with atypical symptoms and history of travel to endemic regions.

High prevalence and mortality due to Histoplasma capsulatum in the Brazilian Amazon: An autopsy study.

BackgroundHistoplasmosis is acquired by inhalation of spores of the dimorphic fungus Histoplasma spp. Although this pathogen is distributed worldwide, it is more prevalent in the Americas. However, the real burden of histoplasmosis remains undefined in many endemic regions.MethodologyWe conducted a series of 61 autopsies to individuals who died in a hospital in the Brazilian Amazon focused on infectious diseases. We performed a detailed histological and microbiological evaluation with genetic characterization of Histoplasma strains with the aim to evaluate the contribution of histoplasmosis to morbidity and mortality. Additionally, we assessed the clinicopathological correlation.Principal findingsEvidence of Histoplasma infection was detected in 21 patients (34%). Eight cases were disseminated infections, all of them occurred in HIV-positive patients. Six cases were localized histoplasmosis, limited to the lungs. In seven patients Histoplasma DNA was detected by PCR in patients with no histological lesions. Histoplasma infection was detected in 38% of HIV-positive patients and was a major contributor to death in 22% of them. Lungs, liver and spleen were affected in all cases of disseminated histoplasmosis. Phylogenetic analysis of the strains suggested a high diversity of Histoplasma species circulating in the Brazilian Amazon. Histoplasmosis was clinically missed in 75% of the disseminated infections.ConclusionsThe high incidence of histoplasmosis, the low index of clinical suspicion, and the severity of the disseminated disease highlight the need of proactively implementing sensitive routine screening methods for this pathogen in endemic areas. Antifungal prophylaxis against Histoplasma should be encouraged in the severely immunocompromised HIV patients in these areas. In conclusion, substantial mortality is associated with disseminated histoplasmosis among HIV-positive patients in the Brazilian Amazon.

#26: Rhino-Orbital Mucormycosis in Immunocompromised Children: Treatment Outcomes of Three Cases

Abstract Background Mucormycosis is an aggressive opportunistic fungal infection of the family Mucoraceae, including the genera Mucor, Absidia, and Rhizopus. It is the third most common cause of invasive fungal infection, with low incidence, but high mortality (50–90%), and it usually presents in immunocompromised hosts. The fungus spores are ubiquitous in nature and are found in soil, air, and on decaying vegetation. Individuals get infected following inhalation of spores, ingestion, or contamination of wounds. Rhino-orbito-cerebral mucormycosis is the most common form of illness in children. An early diagnosis and a multidisciplinary approach to treatment are necessary to prevent mortality. Methods We present a case series of three immunocompromised children with rhino-orbital mucormycosis in Nacional Medical Center “20 de Noviembre” from 2015 to 2019. We describe time to diagnosis, start of antifungal therapy, surgery involvement, and patient outcomes. Results Patient 1 was a 9-year-old girl with aplastic anemia who developed right palpebral swelling (day 1 of initial symptoms) and was initially diagnosed with preseptal cellulitis. On day 5, a necrotic area appeared in the right inner canthus. Paranasal sinus CT scan showed opacified ethmoidal sinus. Liposomal amphotericin B therapy was started. At day 7, surgical debridement was performed. At day 18, the patient died and the culture of the debrided tissue showed Mucor ramosissimus. Patient 2 was a 15-year-old boy with acute lymphoblastic leukemia who developed a necrotic area in right side of the nose and palate (day 1). Liposomal amphotericin B therapy was initiated. At day 3 and 6, surgery was performed. At day 8, cultures resulted in Rhizopus oryzae, and treatment with caspofungin was added. He had progression of the infection, requiring multiple interventions. Antifungal therapy consisted of 75 days with amphotericin B and 67 days with caspofungin, with resolution. At day 152, he had a event of neutropenia and fever and died of septic shock Patient 3 was a 16-year-old girl with acute lymphoblastic leukemia who developed a necrotic lesion on the palate and right side of the nose (day 1). Direct examination of the lesion showed hyaline, non-septated hyphae. Amphotericin B therapy was initiated and surgery was performed at day 3. By day 7, there was good clinical evolution and resolution the infection. She died at day 12 because of intestinal bleeding and hypovolemic shock. Conclusions The diagnosis and treatment of mucormycosis remains a challenge. Clinical suspicion should be high in patients with risk factors, and early identification and prompt treatment with antifungals and surgical debridement can reduce mortality and improve the prognosis. The poor outcomes of the patients in this case series were mainly due to complications of the underlying disease and not because of mucormycosis. However, in the first case, delayed diagnosis and treatment might have contributed to the unfavorable outcome. The treatment of choice is liposomal amphotericin B. In case 2, a second antifungal therapy included caspofungin due to isolation of R. oryzae, sensitive to echinocandins. Posaconazole can be considered as an alternative option, but it is not available at our institution. Early identification of clinical manifestations and early multidisciplinary treatment with surgical services and antifungal are needed to eliminate the infection. Risk factors must be modified to increase patient survival.

MANAGEMENT OF ORAL MUCORMYCOSIS IN A DIABETIC PATIENT:A CASE REPORT

Mucormycosis is a fulminant opportunistic fungus that primarily affects immunocompromised persons. Inhalation of fungal spores causes infection in the nose and paranasal sinuses. The fungus infiltrates the arteries, causing thrombosis and necrosis of the hard and soft tissues of maxillary region. We present a case of mucormycosis-induced maxillary necrosis in a diabetic patient and patient was on amphotericin B for past few days. Early diagnosis and prompt surgical approach like maxillectomy was performed can reduce the mortality and morbidity of this lethal fungal infection.