Fungal Stains Research Articles

Gastric Sarcoidosis: A Rare Manifestation of the Disease

Sarcoidosis is a chronic systemic inflammatory disease of unclear etiology characterized by non-caseating granulomas. It can affect nearly every organ system. Alimentary tract sarcoidosis is atypical within which gastric sarcoidosis is the most common form. Involvement of the alimentary tract is usually as a part of systemic disease or rarely as an isolated finding. Symptomatic gastric sarcoidosis is further more distinct. We present a rare case of sarcoidosis initially presenting with gastrointestinal symptoms and without pulmonary symptoms. A 57 years old morbidly obese African American female with PMH of HTN and DM type II presented with epigastric abdominal pain, nausea, vomiting, and a six month history of unintentional 60lb weight loss secondary to early satiety and dysgeusia. She was found to have hypercalcemia of 13.4 mg/dL, AKI and lactic acidosis. A non-contrast CT and subsequent CTA of the abdomen and pelvis showed small bowel wall thickening, abdominal lymphadenopathy, patent celiac axis and mesenteric vessels, and numerous ˜1mm lung base nodules. EGD revealed erythematous mucosa of gastric antrum with erosions and shallow duodenal erosions (Image 1). Gastric biopsy revealed granulomatous inflammation. Duodenal biopsy showed mild villous blunting without granulomas. Stains for fungal elements and AFB was negative. No intestinal metaplasia, dysplasia or malignancy was noted. PTH, PTHrP, and TSH were normal. CT chest revealed centrilobular nodular interstitial opacities with extensive bilateral mediastinal and hilar lymphadenopathy (Image 2). FNA of right hilar lymphadenopathy under EBUS revealed epithelioid histiocytes and lymphocytes suggestive of granulomatous inflammation. No malignant cells were seen. Fungal and AFB stains and AFB culture were negative. PPD skin test was negative. Patient's GI symptoms improved with supportive care. Given the lack of pulmonary symptoms, corticosteroids were not started. Patient has continued to do well during subsequent clinic follow up. Gastric sarcoidosis is among the rarer subsets of the disease. Most cases have been described as posthumous discoveries on autopsy of known sarcoidosis patients as patients are usually asymptomatic. Biopsy proven pulmonary and gastric sarcoidosis presenting with GI symptoms and an anomalous lack of pulmonary symptoms is exceptionally rare and questions a broader understanding for consideration of sarcoidosis diagnosis.2704_A Figure 1. Erythematous mucosa of gastric antrum with erosions on EGD. H. pylori negative.2704_B Figure 2. CT Chest: Centrilobular nodular interstitial opacities throughout both lungs with moderate mediastinal, hilar, and upper abdominal lymphadenopathy

Fungal Peptic Ulcer Disease in an Immunocompetent Patient

The lifetime prevalence of peptic ulcer disease (PUD) is 5-10%. While PUD is most commonly associated with Helicobacter pylori infection or the use of nonsteroidal anti-inflammatory drugs (NSAIDs), less common causes of PUD should be considered in the differential diagnosis. Peptic ulcer diseaes secondary to Candida in immunocompetent patients is uncommon. We describe a case of endoscopic and histologic resolution of peptic ulcer disease related to Candida infection in a healthy, immunocompetent woman. A 50 year-old woman presented with a three month history of post-prandial abdominal cramping, vomiting and seven pound weight loss. There was no history of HIV (human immunodeficiency virus) or diabetes. She denied NSAID use and alcohol consumption and was not taking corticosteroids. Outpatient esophagogastroduodenoscopy (EGD) revealed a 1 cm, non-bleeding, irregular shaped, deep and clean-based ulcer at the pylorus. Histopathology of the biopsies taken revealed an ulcer with necroinflammatory debris and fungal organisms, consistent with Candida species. Periodic acid-Schiff (PAS) fungal stain noted scattered yeast colonizing the fibrinous debris. After a three week course of fluconazole, her symptoms resolved. Repeat EGD revealed ulcer healing. Repeat biopsies of the pylorus were negative for any evidence of fungal organisms. Fungal PUD is more common in the esophagus compared to anywhere else in the GI tract. Gastric candida was found in 0.24% of patients in a large study consisting of outpatient setting. While treatment guidelines have not been established, antifungals and proton-pump inhibitiors have been shown to help resolve this condition.2689_A Figure 1. Endoscopy before resolution. Fungal ulcer at the pylorus.2689_B Figure 2. Periodic acid-Schiff showing fungal elements.2689_C Figure 3. Endoscopy showing resolution of fungal ulcer at pylorus.

Invasive pulmonary aspergillosis in patients with solid tumours: risk factors and predictors of clinical outcomes

Background: The characteristics and management of invasive pulmonary aspergillosis (IPA) in patients with hematologic malignancies are well known, but IPA in patients with solid tumours is not well described.Methods: We retrospectively reviewed all Aspergillus-positive cultures at a tertiary cancer center during 2004–2017. We identified 101 patients with IPA and solid tumours. We analyzed the association between clinical features and treatment and 12-week mortality and response to antifungal therapy.Results: Fifty-one patients had lung cancer, 77 had underlying lung disease, 47 received chest radiation and 33 had chronic obstructive pulmonary disease. Aspergillus fumigatus was the most common type isolated (71%); 68 patients (70%) were treated with voriconazole monotherapy. Independent risk factors for 12-week mortality included receiving steroids within 30 days of diagnosis (hazard ratio 2.2, 95% confidence interval [CI]: 1.1–4.6; p = .03) and chest radiotherapy (hazard ratio 2.6, 95% CI: 1.2–5.5; p = .01). In multivariate analysis, a positive fungal stain was associated with lower odds of a successful response (odds ratio 0.2; 95% CI: 0.05–0.75; p = .02), whereas voriconazole treatment was associated with higher odds (odds ratio 10.1; 95% CI: 2.1–48.5; p < .01).Conclusions: IPA should be considered in patients with solid tumours, particularly those with underlying lung disease.Key messagesInvasive pulmonary aspergillosis should be considered in patients with solid tumours, particularly those with underlying lung disease, lung cancer and those who received chest radiotherapy.Most of the patients with invasive pulmonary aspergillosis and solid tumours presented with nonspecific symptoms and signs as well as nonspecific CT findings. Unlike patients with hematologic malignancies, fever and hemoptysis were not predominant symptoms and the classical halo sign and the air-crescent sign were not described.Independent risk factors for 12-week mortality included receiving steroids within 30 days of diagnosis and chest radiotherapy. In multivariate analysis, a positive fungal stain was associated with lower odds of a successful response to antifungal therapy, whereas voriconazole treatment was associated with higher odds.

Influence of Natural and Artificial Weathering on the Colour Change of Different Wood and Wood-Based Materials

The importance of the aesthetic performance of wood is increasing and the colour is one of the most important parameters of aesthetics, hence the colour stability of twelve different wood-based materials was evaluated by several in-service and laboratory tests. The wood used for wooden façades and decking belongs to a group of severely exposed surfaces. Discolouration of wood in such applications is a long-known phenomenon, which is a result of different biotic and abiotic causes. The ongoing in-service trial started in October 2013, whilst a laboratory test mimicking seasonal exposure was performed in parallel. Samples were exposed to blue stain fungi (Aureobasidium pullulans and Dothichiza pithyophila) in a laboratory test according to the EN 152 procedure. Afterwards, the same samples were artificially weathered and re-exposed to the same blue stain fungi for the second time. The purpose of this experiment was to investigate the synergistic effect of weathering and staining. The broader aim of the study was to determine the correlation factors between artificial and natural weathering and to compare laboratory and field test data of fungal disfigurement of various bio-based materials. During the four years of exposure, the most prominent colour changes were determined on decking. Respective changes on the façade elements were significantly less prominent, being the lest evident on the south and east façade. The results showed that there are positive correlations between natural weathering and the combination of artificial weathering and blue staining. Hence, the artificial weathering of wood-based materials in the laboratory should consist of two steps, blue staining and artificial weathering, in order to simulate colour changes.

Stains versus colourants produced by fungi colonising paper cultural heritage: A review

Abstract Books, prints, drawings, watercolours, engravings, as well as all other works of art based on paper, are very susceptible to fungal development. The excreted substances and the fungal structures themselves are often coloured and interfere with the readability of the artefacts, diminishing their artistic and monetary value. In order to direct cleaning methods for specific fungal stains on paper, the colourants (molecules) responsible for those stains need to be assessed. However, the literature regarding fungal stains on paper and colourants produced by those fungi is very dispersed and scarce. Therefore, the main objectives of this work were surveying the most common stains on paper, the colourants present on those stains and the main fungi responsible for these colourants’ production. To achieve these goals, two different but complementary literature reviews were made: one on paper conservation literature, where fungal stains observed on paper cultural heritage are reported; and another survey on the chemical/food/pharmaceutical fields where colourants’ molecules produced by fungi, that can colonise paper cultural heritage, are identified and studied in greater detail. This paper presents the first literature review on this subject. The results show that the fungal genera more frequently related with fungal stains on paper cultural heritage are Aspergillus (29%) and Penicillium (13%). The most common colour of the stains is brown (54%), caused by foxing in most of the cases. However, in the paper conservation literature, no consistent correlation has been observed between stain colour on paper/specific fungal species and colourants/chemical compounds. On the literature review regarding the use of fungal colourants for industrial/commercial purposes, the referred colourants can be mostly classified chemically as carotenoids and polyketides. Biosynthetically, most colourants produced by fungi are polyketide-based and representative classes may include chemical structures such as azaphilones, anthraquinones, hydroxyanthraquinones, naphthoquinones and other structures. From a total of 80 different colourants, the ones mostly produced by paper colonising fungi were polyketide quinones, namely the hydroxyanthraquinoid (HAQN) colourants. This review showed that the most commonly studied colours are yellow and red, followed by orange. The production of these colourants is often associated with the genera Aspergillus sp. and Penicillium sp. which are frequently found on stained paper. Overall, there is no doubt that colourants producing fungi are a serious problem to paper conservators, since there is a great variety of colourants produced by different species of fungi colonising paper. This review catalogues the fungal genera, species and excreted colourants mentioned in the literature as being responsible for staining paper cultural heritage.

Protocolo diagnóstico y tratamiento empírico de la neumonía en el paciente inmunocomprometido

Filamentous fungi, respiratory or herpes group, P. jirovecii, Nocardia and M. tuberculosis viruses can cause pneumonia in the immunosuppressed patient. These are mixed infections in 20% of cases. The type of infiltration (alveolar, interstitial or nodular pattern) and whether it is focal or diffuse can give a guide as to the aetiology of the infection. Bacterial, mycobacterial, fungal and viral stains and cultures from respiratory sampling (sputum, nasopharyngeal exudate, BAL), and detecting markers in BAL fluid (viral or fungal PCR, galactomannan, beta-D-glucan) are essential for diagnosis. Diffuse lesions usually require transbronchial biopsy and nodules require percutaneous CT-guided needle biopsy. Empirical treatment for focal involvement and alveolar pattern will include an antipseudomonal beta-lactam. ± amikacin ± vancomycin or linezolid (+ voriconazole if the image is nodular). Antipseudomonal beta-lactam ± vancomycin or linezolid + cotrimoxazole ± ganciclovir is recommended for cases of bilateral and diffuse involvement (alveolar or interstitial).

Mycobacterium marinum Infection in a Post-Katrina Carpenter: The Importance of Exposures

Mycobacterium marinum is typically seen in patients who have a history of exposure to aquariums. We report a unique case of M. marinum that developed on the right knee following participation in a Hurricane Katrina reconstruction project. We are hopeful that this report will alert providers to elicit a thorough history and include cultures for less commonly encountered infectious agents along with routine bacterial and fungal stains and cultures when seeing patients with particular exposure histories such as this.

Polyesterification of wood using sorbitol and citric acid under aqueous conditions

ABSTRACTThe aim of this research is to determine if the polyesterification of sorbitol and citric acid in wood has a future potential as a wood modification process. Pine wood was impregnated with an aqueous solution containing citric acid and sorbitol and was thereafter cured at 103 or 140°C for 18 hours. The dimensional stability and leaching resistance were studied for both modification temperatures. The leachates from the modified wood samples were analysed by HPLC and the susceptibility to decay and staining fungi were studied. Impregnated samples cured at 140°C showed a permanent (leach-resistant) increased dimensional change, but samples treated at 103°C were not stable to leaching. Treated samples cured at 103 and 140°C showed significant resistance to white-rot (Trametes versicolor) and brown-rot decay (Postia placenta) after a leaching procedure. Furthermore, samples cured at 103 and 140°C (leached and unleached) were significantly less susceptible to blue-stain fungi than the untreated controls.

ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA) - A CASE REPORT

Case presentation: We present the case of a diabetic 73 year old male who worked as a farmer, with infiltrates in the right lower and middle lung lobes and with previous diagnosis of chronic obstructive bronchitis. Evaluation of our patient led to the diagnosis of allergic bronchopulmonary aspergillosis in the right lower and middle lobe. Fungal stains were positive for aspergillus. Based on the clinical, radiological and cytological findings, the patient was diagnosed with pulmonary aspergillosis and treated successfully with oral itraconazole and methylprednisolone. Systemic antifungal therapy plays an important role in preventing the morbidity and mortality. He was treated with oral methylprednisolone and itraconazole. Conclusion: Aspergillus infection after the inhalation of spores in the form of a hypersensitivity reaction and saprophytic colonization can be coexistent.

Weathering of wood coated with semi-clear coating: Study of interactions between photo and biodegradation

In order to clarify the relationship between photodegradation and biological degradation, wood specimens finished with a semi-clear coating were degraded under a xenon lamp for different periods of time. The specimens were then inoculated one of two black stain fungi (Aureobasidium pullulans and Epicoccum nigrum). Colonization was monitored visually and by colorimetric analyses. The extent and the nature of the degradation were evaluated using different techniques. The chemical composition was studied by Fourier Transform Infrared Spectroscopy (FTIR) and the physical changes by both microscopic analyses and adhesion tests. The results obtained from FTIR did not provide relevant information. Coating thickness and adhesion were found to decrease as photodegradation increased. Microscope observations detected numerous bubbles trapped in the coating films. These bubbles were found to become holes following photodegradation and the decrease in coating thickness. It was established that more severe photodegradation led to more extensive colonization of the specimens. The fungi seemed to use transpressorium to go through the protective layer and take advantage of organic matter present at the wood/coating interface. Funguscolonization was also found to decrease the coating adhesion in the early stages of the exposure process.

317 Evaluating the Utility of the Fungal Stain in the Microbiology Laboratory

317 Evaluating the Utility of the Fungal Stain in the Microbiology Laboratory

Fungal sinusitis: Sinuses and beyond

Fungal sinusitis poses a great diagnostic and treatment challenge to the otorhinolaryngologist. The increasing incidence of the disease, wide spectrum of clinical features, possibility of recurrence, invasion to vital structures such as orbit and brain, and treatment challenges make it a major health burden today. Often attributed to an immunoglobulin E-specific reaction or cell-mediated immune response to the fungal filaments, fungal sinusitis can be diagnosed by fungal stain and culture and histopathology (gold standard). Radiological studies help in assessing the disease extent and in planning management. We present our series of various forms of fungal sinusitis and the difficulties we faced in the management and the outcome. Each form of fungal sinusitis has distinctly different medical and surgical treatment which needs to be individualized, most often requiring radical surgical debridement along with adjunct long-term antifungals (polyene and triazole) playing an equally important role.

Pulmonary Histoplasmosis in a patient with Cough, Dyspnea, Pulmonary Nodule and Rheumatologic Manifestations: Case Report and Review

In this case report we describe a case of pulmonary histoplasmosis in a healthy adult female living in Kentucky. The patient presented with two months history of poly-arthralgia and myalgia, intermittent dry cough, chest tightness, exertional dyspnea, malaise, fatigue and one week history of skin rash. She did not respond to broad-spectrum antibiotic therapy and she also had extensive endocrine and rheumatologic work up that was negative. A diagnosis of histoplasmosis was established based on radiological findings as well as endobronchial ultrasound-guided transbronchial needle aspiration cytology (EBUS-TBNA) of mediastinal lymph nodes demonstrating necrotizing granuloma with fungal stains positive for Histoplasma. Patient showed significant clinical improvement on antifungal treatment. Since symptoms of histoplasmosis are often similar to the symptoms of community acquired pneumonia, other lung infections or malignancy, our case highlights the importance of maintaining a high index of suspicion and appropriate radiological, microbiology, and histologic evaluation especially in patients who live in or have traveled to areas endemic for histoplasmosis and are not responding to antibiotic therapy. Early diagnosis coupled with prompt initiation of antifungal treatment may lead to favorable outcomes.

Inflamed Bowels, Now Inflamed Lungs: A Case Report of Pulmonary Necrobiotic Nodules in Crohn's Disease

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary necrobiotic nodules have been described as a rare extraintestinal manifestation of Crohn’s disease. We report imaging and pathological findings of this rare disease entity. CASE PRESENTATION: A 21-year-old gentleman with a longstanding history of Crohn’s disease presented with 2 weeks of right-sided pleuritic chest pain, associated with a dry cough. He did not report fevers, night sweats, abdominal pain or diarrhea. The patient had achieved remission of his Crohn's disease for 11 years with adalimumab, which was discontinued 2 months prior to presentation due to concerns of developing secondary lymphomas. He was then transitioned to mesalamine, after which he experienced a self-limited episode of Crohn’s disease exacerbation. On presentation, he was hemodynamically stable. Physical examination was notable for right-sided chest tenderness. Laboratory investigations showed an elevated erythrocyte sedimentation rate of 33 mm/hr and D-dimer of 535 µg/mL. A computed tomography (CT) scan of the chest showed multiple nodular appearing opacities bilaterally (figure 1). Lung biopsy revealed areas of parenchymal necrosis with necrotizing granulomas. The necrosis was basophilic, which contained nuclear debris and eosinophils with the surrounding inflammatory infiltrates (figure 2). Gram stain, acid-fast bacilli stain, fungal stain and tissue culture were all negative. Angiotensin-converting enzyme level was normal. Cytoplasmic antineutrophil antibodies titer was 1:40, myeloperoxidase and proteinase-3 antibodies were not detected. The differential diagnosis was primary vasculitis versus Crohn’s disease associated necrobiotic nodules. The lack of systemic manifestations lowered the suspicion for active vasculitis. The patient had an uneventful recovery. Mesalamine was changed to vedolizumab. Repeat chest CT scan 2 months later showed marked reduction in size and number of the pulmonary nodules. 5 months after presentation chest CT showed complete resolution of the previously noted pulmonary nodules. DISCUSSION: Our case demonstrates a rare pulmonary complication related to Crohn’s disease exacerbation, which is the development of pulmonary necrobiotic nodules. We suspect that this was the consequence of therapy de-escalation. Our hypothesis is supported by the complete resolution of pulmonary nodules following therapy re-escalation. CONCLUSIONS: Even after achieving Crohn's disease remission for a long period of time, therapy de-escalation still carries the risk of triggering unexpected pulmonary manifestations. Physicians should consider risks versus benefits of alternate therapy. In clinical practice, it is important to maintain a broad differential diagnosis, especially in patients with conditions affecting multi-organ systems. Reference #1: Warwick, G., Leecy, T., Silverstone, E., Rainer, S., Feller, R., & Yates, D. H. (2009). Pulmonary necrobiotic nodules: a rare extraintestinal manifestation of Crohn's disease. European Respiratory Review, 18(111), 47-50. DISCLOSURE: The following authors have nothing to disclose: Mahmoud Ahmed, Laurie Lerner No Product/Research Disclosure Information

TB of Porta Hepatis Presenting With Obstructive Jaundice: A Case Report

Introduction: Mycobacterium Tuberculosis causes tuberculosis. The number of reported TB cases in United States has been decreasing each year in the last 2 decades. Extra pulmonary TB can present anywhere in the body, however isolated peri-pancreatic or hepatobiliary TB is rare. Case Report: 25-year-old Pakistani immigrant male presented with 2 weeks of vague RUQ pain, pruritus, fever, nausea, acolic stool and dark urine. On exam: RUQ abdominal tenderness, yellow skin discoloration. AST 107 IU/L, ALT 211 IU/L, ALP 273 IU/L, LDH 214 IU/L, total bilirubin 11.4 mg/dl, indirect bilirubin 4 mg/dl, direct bilirubin 7.4 mg/dl. US showed a mass in the pancreatic area. CT showed a 5.5x4.1x4.8 cm complex cystic mass in the region of Porta Hepatis with resultant intrahepatic biliary dilatation that extends to the level of mass as well as 1.4 cm intra-aortocaval lymph node. Emergency ERCP with biliary stent placement was performed. FNA of the intra-aortocaval lymph node was performed. Biopsy: granulomatous inflammation, negative for malignant cells, fungal or AFB stains; the PCR positive for M. Tuberculosis DNA. CT chest: bulky non-calcified right Para-tracheal lymph node (1.5x2.7 cm). Mediastinoscopy was performed with lymph node biopsy: granulomatous inflammation, stains for AFB and fungi negative, PCR positive for M.Tuberculosis. T spot TB test was positive. Patient improved with stent placement and started on Isoniazid, Rifampin, Pyrazinamide and Ethambutol (2 months), followed by INH and Rifampin (4 months). Follow up imaging: complete resolution of the porta hepatis mass and lymph nodes. Discussion; Abdominal TB presents in one or more of the following forms: tuberculous lymphadenopathy, peritoneal tuberculosis, GI tract tuberculosis and visceral tuberculosis. Abdominal TB can occur due to hematogenous route, inhaling the tuberculosis spores, tubercular focus can develop in the lung from which hematogenous spread to other body parts takes place or ingestion of bacteria and then translocation across the intestinal wall. Diagnosis is made by demonstration of granulomas or AFB on Zeil-Neelson stain (low diagnostic value). PCR can effectively detect mycobacterium DNA in tissue sample. Early treatment with Quadruple therapy can effectively treat abdominal TB. Conclusion: Porta hepatis TB diagnosis is challenging and often confused with malignancy with high mortality risk if left untreated. Clinical outcome improves significantly with anti-Tuberculosis drugs.Figure: CT Abdomen, axial section, showing mass in porta hepatis area.Figure: CT abdomen, coronal section, showing mass in porta hepatis area with resultant intrahepatic biliary dilatation.Figure: CT abdomen, axial section, showing CBD stent with resolution of porta hepatis mass.

An Atypical Cause of Hemoptysis

SESSION TITLE: Fungal Infections 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Cryptococcus presenting as an endobronchial mass lesion is rare. We present an unusual case of pulmonary cryptococcosis in an immunocompetent patient encountered in clinical practice. CASE PRESENTATION: Patient is a 48y/o AAF with a past medical history notable for cough variant asthma, and hypertension. She had a persistent cough for many years. Initial imaging performed for work-up of her chronic cough was unremarkable. Full pulmonary function test were normal. Ig E levels were elevated at 255 kU/L with immunocap testing revealing high levels of reactivity to dust mites, animal dander and grasses. The patient was managed with formoterol/ mometasone and an albuterol rescue inhaler as needed with variable compliance. She presented for re-evaluation after she noted a change in her cough for several months. Her cough had initially been dry but had become productive a small amount of blood tinged sputum. She was seen in the emergency department shortly after the onset of hemoptysis and was told that she had pneumonia. She was discharged on a 7 day course of levofloxacin without a significant improvement in her symptoms. CT scan of the chest performed 3 months after the onset of symptoms showed a right lower lobe mass like consolidation (Figure 1). The patient continued to experience a chronic cough with intermittent hemoptysis, describing it as “puddles of blood in my phlegm” more frequently in the morning. At that time, she also complained of worsening dyspnea with exertion, polyarthralgias and fatigue. Antinuclear antibody, antineutrophil cytoplasmic autoantibodies and rheumatoid factor were negative. Fiberoptic bronchoscopy revealed an endobronchial mass obstructing the one of the right lower lobe medial basilar subsegments. Bronchoalveolar lavage demonstrated budding yeasts, positive fungal stains and endobronchial biopsy of the mass had innumerable intracellular yeast forms with a clear capsule suggestive of Cryptococcus (figure 2). Patient was started on itraconazole. DISCUSSION: The clinical presentation of Cryptococcus is highly variable and often related to the burden of exposure, virulence factor or quality of immune response[1]. In the immunocompetent host primary infection is usually asymptomatic. These patients are usually identified incidentally by abnormal chest imaging or on biopsy of a lung mass or on cultures of lung specimens obtained for other reasons[2,3]. Cough is the most common pulmonary symptom if the patient is symptomatic. CONCLUSIONS: Pulmonary cryptococcosis has a wide range of presentations and should be considered as a cause of chronic cough even in immunocompetent patients. Reference #1: Jarvis JN1, Harrison TS. Pulmonary cryptococcosis. Semin Respir Crit Care Med. 2008 Apr;29(2):141-50. doi: 10.1055/s-2008-1063853. Reference #2: Lindell RM1, Hartman TE, Nadrous HF, Ryu JH. Pulmonary cryptococcosis: CT findings in immunocompetent patients. Radiology. 2005 Jul;236(1):326-31. DISCLOSURE: The following authors have nothing to disclose: Valentina Amaral, Kala Davis-McDonald No Product/Research Disclosure Information

Successful Treatment of Pulmonary Cunninghamella Bertholletiae Infection With Liposomal Amphotericin and Posaconazole in an Elderly Male With Psoriatic Arthritis on Immunosupression

SESSION TITLE: Unusual Pulmonary Infections SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Cunninghamella bertholletiae is a species of zygomycetous fungi in the order Mucorales. It is a saprophytic and ubiquitous fungus found mainly in soil.It is an opportunistic fungal infection seen predominantly in immunocompromised patients,people with leukemia and uncontrolled diabetes causing extremely high mortality rate. Cunninghamella bertholletiae infections are often highly invasive, and can be difficult to treat making prompt and accurate diagnosis of this pathogen an important medical concern.Disseminated infections have also been seen in renal and hepatic transplant patients.Infection usually occurs through traumatic introductions into the body (i.e. through a wound). CASE PRESENTATION: 68 year old male patient came with complaints of high grade fever, cough and shortness of breath grade ΙΙ of 10 days duration.Patient had history of psoriatic arthritis for 3 years and was on multi-drug immunosuppression including corticosteroids,methotrexate,leflunomide.He had type 2 diabetes mellitus of 20 years duration.Lung infection was suspected and immunosuppressive therapy was stopped.Patient had hyoxia and required oxygen support, initially 5L/min later increased to 15L/min.He was put on broad spectrum antibiotics including Meropenem,Clarithromycin .CT chest showed B/L extensive subpleural and peribronchovascular ground glass attenuation with septal thickening and areas of consolidation. Bronchoscopy was performed, BAL for fungal stain showed plenty aseptate, branching broad hyphae suggestive of zygomycetes infection. Liposomal amphotericin was started in the dose of 5mg/kg/day. Patient was closely monitored in ICU over the next 10 days in view of persistent hypoxia,tachycardia,tachypnoea and worsening of chest X-ray shadows.He also received intermittent NIV support through face mask.Syrup Posaconazole was added to the regimen after 3 days of starting amphotericin as he continued to have high grade fever.Bronchial wash was negative for bacterial culture,but fungal culture grew Cunninghamella bertholletiae.After 1 week, patient was slowly weaned off from NIV support and required lesser oxygen.Antifungals were continued, he was shifted out of ICU after 14 days with minimal oxygen support.Patient showed significant clinical and radiological improvement and was closely monitored with renal and electrolyte parameters for potential complications of Amphotericin therapy. DISCUSSION: Mucormycosis is manifested by a variety of syndromes in humans, particularly in patients receiving glucocorticoids[1] and those with diabetes mellitus [2].Devastating rhino-orbital-cerebral and pulmonary infections are the most common syndromes caused by these fungi.Pulmonary mucormycosis is a rapidly progressive infection that occurs after inhalation of spores into the bronchioles and alveoli. The diagnosis of pulmonary mucormycosis is difficult since the presentation does not differ from pneumonia due to other angioinvasive molds. Chest radiographs or CT scans may demonstrate focal consolidation, masses, pleural effusions, or multiple nodules [3] but are nonspecific.Dedicated team of pulmonologists and microbiologists with aggressive search for the causative agent and prompt initiation of antifungals is required. CONCLUSIONS: Invasive fungal infections should be suspected in immunocompromised patients and aggresive search for the causative organism should be employed at the earliest.If sputum is non-representative,bronchoscopy and BAL should be done early in the course of the disease,as later on, severe hypoxia might hinder any invasive procedures,increasing the risk of respiratory failure during bronchoscopy. Multidisciplinary approach in consultation with pulmonologist, microbiologist, intensivist. nephrologist is the key in managing these patients. Lastly, due to exhausting hospital stay and economic burden due to expensive anti-fungal drugs,they are prone to anxiety/depression.An empathetic approach and day-to-day counselling of relatives played a significant role in our patient management. Reference #1: Kontoyiannis DP, Wessel VC, Bodey GP, Rolston KV. Zygomycosis in the 1990s in a tertiary-care cancer center. Clin Infect Dis 2000; 30:851. Reference #2: Kauffman CA, Malani AN. Zygomycosis: an emerging fungal infection with new options for management. Curr Infect Dis Rep 2007; 9:435. Reference #3: Chamilos G, Marom EM, Lewis RE, et al. Predictors of pulmonary zygomycosis versus invasive pulmonary aspergillosis in patients with cancer. Clin Infect Dis 2005; 41:60. DISCLOSURE: The following authors have nothing to disclose: Yashwant K O, Vijay Salla, Annapurna Mydavolu, Latha Sarma No Product/Research Disclosure Information

Preliminary analysis of amplicon high-throughput sequencing as a method for the assessment of fungal diversity in discolored wood

AbstractThe diversity of stain fungi is important if wood is inhabited with various fungi, and the discoloration mechanism will be better understood. MiSeq amplicon high-throughput sequencing (Illumina®) is able to detect species richness (the number of species within a community) and species evenness (the sizes of species populations within a community). This study detected fungal diversity in discolored Mongolian pine for the first time by the MiSeq approach, focusing on the nuclear ribosomal internal transcribed spacer-1 (ITS1). The results show that the discolored wood was inhabited by a combination of microorganisms, more than 90% of which belong toAscomycotafungi at the phylum level. The MiSeq method revealed not only all the inhabited fungal species but also their quantitative relation to each other. The dominant fungal species in sample A areHelotiales(34.1%) andHypocreales(20.7%). The dominant fungal species in sample B isNectriaceae(67.9%), whileHypocrea(34.7%) andSporothrix(27.6%) are the dominant fungal species in sample C. It was confirmed via core microbiome analysis that the following fungi were common stain fungi in the three discolored samples:Fusariumspp.,Aspergillusspp.,Sporothrixspp.,Penicilliumspp.,Trichodermaspp.,Alternariaspp. andCladophialophoraspp.

Acid-Fastness of Histoplasma in Surgical Pathology Practice.

BackgroundHistoplasmosis (HP) is diagnosed by visualizing intracellular microorganisms in biopsy and/or culture. Periodic-acid Schiff (PAS) and Gomori methenamine silver (GMS) staining methods are routinely used for identification. The acid-fast property of Histoplasma was identified decades ago, but acid-fast staining has not been practiced in current surgical pathology. Awareness of the acid-fast property of Histoplasma, which is due to mycolic acid in the cell wall, is important in distinguishing Histoplasma from other infective microorganisms. Here, we examined acid-fastness in previously diagnosed cases of Histoplasma using the Ziehl-Neelsen (ZN) stain and correlated those findings with other known fungal stains.MethodsAll cases diagnosed as HP were retrieved and reviewed along with ZN staining and other fungal stains. We also stained cases diagnosed with Cryptococcus and Leishmania as controls for comparison.ResultsA total of 54 patients ranging in age from 11 to 69 years were examined. The most common sites of infection were the skin, adrenal tissue, and respiratory tract. Of the total 43 tissue samples, 20 (46.5%) stained positive with the ZN stain. In viable cases, a significant proportion of microorganisms were positive while necrotic cases showed only rare ZN-positive yeasts. In comparison to PAS and GMS stains, there was a low burden of ZN-positive yeasts. Cryptococcus showed characteristic ZN staining and all cases of Leishmania were negative.ConclusionsAlthough the morphology of fungal organisms is the foundation of identification, surgical pathologists should be aware of the acid-fast property of fungi, particularly when there is the potential for confusion with other infective organisms.

Recellularization of a novel off-the-shelf valve following xenogenic implantation into the right ventricular outflow tract.

Current research on valvular heart repair has focused on tissue-engineered heart valves (TEHV) because of its potential to grow similarly to native heart valves. Decellularized xenografts are a promising solution; however, host recellularization remains challenging. In this study, decellularized porcine aortic valves were implanted into the right ventricular outflow tract (RVOT) of sheep to investigate recellularization potential. Porcine aortic valves, decellularized with sodium dodecyl sulfate (SDS), were sterilized by supercritical carbon dioxide (scCO2) and implanted into the RVOT of five juvenile polypay sheep for 5 months (n = 5). During implantation, functionality of the valves was assessed by serial echocardiography, blood tests, and right heart pulmonary artery catheterization measurements. The explanted valves were characterized through gross examination, mechanical characterization, and immunohistochemical analysis including cell viability, phenotype, proliferation, and extracellular matrix generation. Gross examination of the valve cusps demonstrated the absence of thrombosis. Bacterial and fungal stains were negative for pathogenic microbes. Immunohistochemical analysis showed the presence of myofibroblast-like cell infiltration with formation of new collagen fibrils and the existence of an endothelial layer at the surface of the explant. Analysis of cell phenotype and morphology showed no lymphoplasmacytic infiltration. Tensile mechanical testing of valve cusps revealed an increase in stiffness while strength was maintained during implantation. The increased tensile stiffness confirms the recellularization of the cusps by collagen synthesizing cells. The current study demonstrated the feasibility of the trans-species implantation of a non-fixed decellularized porcine aortic valve into the RVOT of sheep. The implantation resulted in recellularization of the valve with sufficient hemodynamic function for the 5-month study. Thus, the study supports a potential role for use of a TEHV for the treatment of valve disease in humans.