Unusual Fungal Infections Research Articles

Refractory Post-Operative Wound Infection by Arthrographis Kalrae: A Case Report and Review of Literature

Arthrographis kalrae (A. Kalrae) infections, although rare, have often demonstrated an extended clinical course. We report a case of refractory post-operative wound infection with A. Kalrae after radical soft tissue and femur resection following total femoral replacement. Identification of A. Kalrae was done based on detailed microscopic and phenotypic characteristics and biochemical tests. Additionally, it was confirmed with sequencing. Although antifungal therapy was started on the basis of the breakpoints observed, clinical failure was met. However, wound infection was subsequently controlled with extensive tissue debridement and a combination of antifungal drug therapy over a period of 33 weeks. The rarity of global data about such unusual fungal infections adds to diagnostic and therapeutic challenges.

Development and validation of a preliminary multivariable diagnostic model for identifying unusual infections in hospitalized patients.

Diagnostic delay leads to poor outcomes in infections, and it occurs more often when the causative agent is unusual. Delays are attributable to failing to consider such diagnoses in a timely fashion. Using routinely collected electronic health record (EHR) data, we built a preliminary multivariable diagnostic model for early identification of unusual fungal infections and tuberculosis in hospitalized patients. We conducted a two-gate case-control study. Cases encompassed adult patients admitted to 19 Mayo Clinic enterprise hospitals between January 2010 and March 2023 diagnosed with blastomycosis, cryptococcosis, histoplasmosis, mucormycosis, pneumocystosis, or tuberculosis. Control groups were drawn from all admitted patients (random controls) and those with community-acquired infections (ID-controls). Development and validation datasets were created using randomization for dividing cases and controls (7:3), with a secondary validation using ID-controls. A logistic regression model was constructed using baseline and laboratory variables, with the unusual infections of interest outcome. The derivation dataset comprised 1043 cases and 7000 random controls, while the 451 cases were compared to 3000 random controls and 1990 ID-controls for validation. Within the derivation dataset, the model achieved an area under the curve (AUC) of 0.88 (95% confidence interval [CI]: 0.87-0.89) with a good calibration accuracy (Hosmer-Lemeshow P = 0.623). Comparable performance was observed in the primary (AUC = 0.88; 95% CI: 0.86-0.9) and secondary validation datasets (AUC = 0.84; 95% CI: 0.82-0.86). In this multicenter study, an EHR-based preliminary diagnostic model accurately identified five unusual fungal infections and tuberculosis in hospitalized patients. With further validation, this model could help decrease time to diagnosis.

Cryptococcus laurentii: An unusual cause for atypical pneumonia in hematological malignancy

Cryptococcus laurentii, one of the nonneoformans Cryptococcus is a known biopesticide to control fruit rot, previously considered to be nonpathogenic to humans, is now have been reported as a cause of opportunistic infections. Here, we present a case of pulmonary cryptococcosis due to C. laurentii in a patient with chronic lymphocytic leukemia and prolymphocytic leukemia. Sputum microscopy showed Gram-positive spherical capsulated budding yeast cells, culture of which revealed it as C. laurentii. The patient was promptly put on fluconazole, but he died on the subsequent day after initiation of therapy. A high index of suspicion and improvement of techniques of culture and identification is essential for early diagnosis and treatment of unusual fungal infections.

Multiple eumycetomas caused by Pyrenochaeta romeroi in a renal allograft recipient

The incidence of unusual fungal infections in renal allografts has been rising in the last few years. We report an unusual case of eumycotic mycetomas at multiple sites caused by a fungus Pyrenochaeta romeroi, in a 43-year-old male, farmer by occupation and renal allograft recipient. The patient had undergone a live, related donor transplant 9 months earlier, with wife as donor, and was on tacrolimus, mycophenolate mofetil and steroids. This is the only case of P. romeroi causing nodular eumycetomas at multiple sites in a renal allograft recipient. All case reports have reported single lesion and multiple lesions are uncommon.

Unusual fungal infections in renal transplant recipients.

Fungal infections are an important cause of morbidity and mortality in renal transplant recipients. The causative agent and the risk factors differ depending on the period after the kidney transplant. Also the incidence varies according to the geographical area. We are reporting three cases of fungal infections in renal transplant recipients. Two of them have etiological agents which are common among immunosuppressed patients, but with an atypical clinical presentation, while one of them is a subcutaneous infection caused by a less frequent dematiaceous fungus, Aureobasidium pullulans. These cases highlight how a high index of clinical suspicion and prompt diagnosis is very much essential for better outcome. The emerging fungal infections and paucity of data regarding their management pose a challenge to the transplant physicians.

Trichophyton erinaceikerion barbae from a hedgehog with direct osculatory transfer to another person

We describe a case of kerion tinea barbae infection due to Trichophyton erinacei in a 37-year-old man. The infection had also been transferred to his partner by direct contact from kissing. T. erinacei is a zoophilic dermatophyte occasionally harboured by the hedgehog (Erinaceus europaeus). There are few reports of human infection in the literature, and it rarely causes a kerion. There is only one previous report of tinea barbae occurrence due to T. erinacei. This case highlights the possibility of one of the more unusual fungal infections that can be acquired in the UK, and highlights the necessity of asking specific questions to identify possible sources of infection.

Aureobasidium pullulans infection in a patient with chronic lymphocytic leukemia

Saprophytic fungi are being increasingly recognized as etiologic agents of mycoses in immunosuppressed patients. We report a case of subcutaneous infiltration by Aureobasidium pullulans, likely due to traumatic inoculation, in a neutropenic patient during chemotherapy for chronic lymphocytic leukemia. The patient was treated with amphotericin B deoxycholate but was subsequently switched to itraconazole, which improved the lesion. This case highlights the importance of considering unusual fungal infections in critically ill patients such as those who are immunosuppressed due to chemotherapy. Diagnostic techniques and effective antifungal therapy have improved the prognosis of these cases.

Hospital-related outbreaks due to rare fungal pathogens: a review of the literature from 1990 to June 2011

Fungi can cause severe infections. Two or more nosocomial unusual fungal infections diagnosed in a short period should be assumed as an outbreak. The review's aim was to collect data to improve their management. The free online worldwide database for nosocomial outbreaks ( http://www.outbreak-database.com ) and the PubMed/MEDLINE database were used to collect the English literature published from 1990 to June 2011. The more common Candida spp. and Aspergillus spp. infections were excluded. For each outbreak, the following data were reviewed: species, duration, source and site of infection, ward, risk factors, number of patients infected, treatment, related mortality, type of epidemiological study and time elapsed between index cases and second cases. Thirty-six reports were considered: yeasts caused the majority of the outbreaks (16 out of 36). The median values for the overall duration, number of infected people per outbreak and infection-related mortality were 5months, 4 and 20%, respectively. Eighteen cases were caused by contaminated substances and 13 cases were hypothesised as human-transmitted. Nosocomial outbreaks due to rare fungal pathogens involve few patients but have high related mortality. These results could be explained by the diagnostic delay, the inability of recognising the source of the infections and the challenges of the treatment. More efforts should be concentrated to implement the application of proper hygiene practices to avoid human-human transmission.

Epidemiology of Emerging Fungi and Fungi-like Organisms

Over the past several decades, rare and unusual fungi have been reported increasingly as agents of infection in humans and animals. This increased frequency of unusual fungal infections may be related in part to increasing numbers of patients with immunosuppression, as well as increased opportunities for environmental exposure to the organisms. In addition, the advent of better diagnostic modalities has aided in the identification of unusual organisms. This review discusses the epidemiology of emerging and unusual fungi and other pathogens causing fungal-like infection.

Fungal arthritis of the knee caused by Mycoleptodiscus indicus

Mycoleptodiscus indicus is a recognized plant pathogen which has very rarely been reported as a cause of human infection. It is a tropical or subtropical fungus which is difficult to culture and identify from clinical specimens. This is the first report of septic arthritis with this fungus in a healthy Canadian male. The fungal infection was contracted on a vacation in Costa Rica, probably through direct inoculation through injured skin. The fungus was isolated from synovial fluid and identification was confirmed by DNA sequencing. There has only been one previous case of septic arthritis of the knee and one skin infection reported with this fungus; both cases involved immunocompromised hosts. Both septic arthritis patients required joint surgery and lavage to eradicate the fungus, however, only the immunocompromised patient required antifungal medications. In the future, it is very likely that the number of patients identified with M. indicus infection will rise due to increasing awareness of this pathogen as well as increasing exposure. Many immunocompromised patients on anti-retroviral or biologic therapy are healthy enough to travel, thereby exposing themselves to exotic and infected plants which increase the risk of unusual fungal infections.

Rare and Emerging Fungal Pulmonary Infections

The frequency and diversity of serious fungal infections are increasing. Persons who are severely immunocompromised are particularly vulnerable to infection from unusual molds and yeasts that are often found naturally in the environment. Clinical manifestations from these unusual fungal infections range from colonization of airways to chronic localized lesions to acute invasive or disseminated disease. When present, rare and emerging fungi are often isolated from the respiratory tract during a severely immunosuppressed state, and diagnosis requires isolation and identification of the infecting organism. Histopathology is often required to differentiate tissue invasion from airway colonization. There are no diagnostic serologies, and radiological exams are not specific. Furthermore, many emerging opportunistic molds demonstrate in vitro resistance to the older azoles and amphotericin B. As a result, successful treatment may require adjunct surgical debridement and, when possible, reconstitution of the host immune system. Also, the newer triazoles such as voriconazole and posaconazole may be useful to treat some of these infections caused by rare and emerging molds.

Pneumonia and Pleural Effusion due toCryptococcus Laurentiiin a Clinically Proven Case of AIDS

Non-neoformans cryptococci were previously considered to be saprophytes and nonpathogenic to humans. Cryptococcus laurentii is frequently used as a biological means to control fruit rot. Interestingly, C laurentii has recently been reported to be a rare cause of infection in humans. The authors report a case of pulmonary cryptococcosis caused by C laurentii in a diabetic AIDS patient who was on antituberculosis and antiretroviral treatments. The sputum smear revealed capsulated yeast cells that were identified as C laurentii. Repeated pleural fluid culture revealed growth of C laurentii. Both respiratory samples were negative for acid-fast bacilli. Moraxella catarrhalis and Klebsiella pneumoniae were also found in the sputum, but not in the pleural fluid. The patient had a good response to oral fluconazole therapy at 600 mg/day for five weeks and was then discharged. The present article is the first to report on the rare pulmonary involvement of C laurentii in the Indian HIV population. These unusual forms of cryptococci create a diagnostic predicament in the rapid diagnosis of pulmonary cryptococcosis. A high degree of suspicion and improvement of techniques for culture and identification will contribute to the early diagnosis and treatment of unusual fungal infections.

Unusual Fungal and Pseudofungal Infections of Humans

The spectrum of mycotic disease continues to expand well beyond the familiar entities of candidiasis and aspergillosis ([73][1], [99][2]). The field of medical mycology has become a challenging study of infections caused by a wide and taxonomically diverse array of opportunistic fungi ([73][1]).

Unusual Fungal Infections in the Intensive Care Unit

Unusual Fungal Infections in the Intensive Care Unit

Unusual fungal infections in children with cancer

Unusual fungal infections in children with cancer

Central nervous system complications in renal transplant recipients in a tropical environment

Renal transplant recipients are at risk of developing various infectious and non-infectious complications affecting the central nervous system (CNS). There is paucity of data regarding the spectrum of CNS complications and the epidemiology of infective agents varies according to geographical location. We retrospectively studied the spectrum of CNS complications seen in 792 renal allograft recipients followed up at this tertiary care centre in north India over a 19-year period. Autopsy findings of 78 allograft recipients who died in the hospital were also reviewed and included. The brain was examined in 22 of these patients. Overall, 79 (10%) patients developed some form of CNS dysfunction with a mortality rate of 60.8%. CNS infections occurred in 31 renal allograft recipients (3.9% of total) and accounted for the largest group (39.2%). Fungi were the commonest etiological agents (21 patients) and were associated with a 70% mortality, with cryptococcal meningitis occurring in 12, mucormycosis in six, aspergillosis in one, and other unusual fungal infections in the remaining two patients. All patients with mucormycosis had a fatal outcome. The second largest group comprised of patients with non-uremic encephalopathies (23 patients, 29.1%) with metabolic encephalopathy occurring in 13, toxic encephalopathy in nine and hypertensive encephalopathy in one patient) and was associated with an overall mortality rate of 60.9%. Cerebrovascular accidents occurred in 12 patients (15.2%) and were associated with a mortality of 91.7%. Other CNS complications included treatment related complications in four (5.1%), primary CNS lymphomas in three (3.8%), and miscellaneous complications in six patients (7.6%). Patients with non-cryptococcal fungal infections of the CNS, hepatic and toxic encephalopathy and those with cerebrovascular accidents had the worst outcome. There was no relationship between the development of infection or stroke and the type of maintenance immunosuppression used. We conclude that complications involving the CNS occur in 10% of all renal transplant recipients and are associated a with high mortality, warranting early diagnosis and aggressive treatment.

Fungal Infections in Patients with Leukemia

Polymorphonuclear and mononuclear phagocytes are the leading host cells involved in the prevention and control of fungal infections’. Therefore fungal infection is a frequent complication of disease or chemotherapy-induced neutropenia in acute leukemia. Other predisposing factors include breaks in anatomical barriers such as mucositis, the administration of corticosteroids and antimicrobial treatments and the presence of indwelling catheters. The most common fungal agents encountered are Candida spp. and Aspergillus spp. while infections with Histoplasma, Coccidioides and Blastomyces are restricted to well-defined regions. These result in disseminated disease during neutropenia, after reactivation of long-dormant infection of the lungs. Another important infection, although less frequent than candidiasis and aspergillosis, is mucormycosis which involves mainly the lungs and the paranasal sinuses. Recently, an increasing number of unusual fungal infections have been reported in leukemia including Fusarium, Paecilomyces and Alternaria, Pseudoallescheria, Sporothrix, Trichosporon, and Geotrichum2. Over recent years candidemia and disseminated candidiasis are definitely increasing in leukemic patients. Most of the cases are due to Candida albicans, although in some institutions, it is being supplanted by C. tropicalis. C. krusei has emerged recently while C. parapsilosis is also common among patients receiving total parenteral nutrition. Other fungi, including C. guilliermondii, C. lusitaniae, and Torulopsis glabrata, may infrequently cause fungemia in leukemic patients. Clinical manifestations include fever refractory to antibacterial therapy, cutaneous lesions, myalgia, hypotension, and end~pthalmitis~. Blood cultures are positive in only 35% of the patients with autopsy-proven disseminated candidiasis and serological tests for antibodies are often negative. Detection of mannan antigen, and metabolites such as mannose or arabinitol have low sensitivity and are not reliable. In addition the positive predictive value of surveillance cultures during neutropenia are useful only for C. tropicalis but not for C. albicans4. Nevertheless mortality has decreased in recent years and this may be related to the increasing number of leukemic patients who achieve remission and survive Candida dissemination. This could also explain the recent emphasis on hepatosplenic candidiasis, which appears classically after recovery from neutropenia, with persisting fever, increase in serum alkaline phosphatase levels and hepatosplenic abscesses. Invasive aspergillosis is found in 25 to 40% of leukemic patients and at autopsy most of the cases are due to Aspergillus fumigatus and A. flaws. The risk of infection increases proportionally to the duration of neutropenia5 and the two primary sites of infection are the lungs and the paranasal sinuses. Clinical manifestations include persistent fever, pleuritic chest pain, and cough. Dyspnea and hypoxia appear late while rales are variably present on ausultation. Nasal discharge, epistaxis, facial swelling and tenderness are indicative of sinus infection. Chest and sinuses CT scans are superior to standard X-rays and should be performed on early suspicion. Dissemination to the central nervous system occurs in 10 to 15% of cases and this often results in fatal hemorrhage. The clinical picture of mucormycosis is very similar to that of aspergillosis, although less frequent and often fatal. Several fungi not previously associated with leukemia have recently been reported to cause disseminated infection. These include Fusarium spp., Pseudoallescheria boydii, and Trichosporon spp. The former two produce similar manifestations to aspergillosis and mucormycosis, however, maculopapular cutaneous lesions are more frequent and can produce necrotic ulcers. Another important difference is the isolation from blood.

Saprophytic Molds as Agents of Cutaneous and Subcutaneous Infection in the Immunocompromised Host

Significant advances made in recent years in the treatment of neoplastic disease and the prevention of organ graft rejection have been accompanied by an increase in opportunistic infections.¹Although bacteria still account for most of these infections, the incidence of fungal infections in such patients is rising.^1-4This assault on the immune system by immunosuppressive therapy, including systemic corticosteroids, cytotoxic and antineoplastic drugs, and irradiation with roentgen rays, renders the host susceptible to fungi that normally do not pose a threat to patients with intact immunologic defense mechanisms.^1,3Depletion of the number of neutrophils, defects in neutrophil function, and T-cell defects also predispose the host to fungal infections.³ Although species of<i>Candida</i>and<i>Aspergillus</i>as well as<i>Cryptococcus neoformans</i>and members of the Zygomycetes (Phycomycetes) remain the most common fungal pathogens in the compromised host,²other more unusual fungal infections are being caused by fungi

Tropical and Unusual Superficial Fungal Infections

The authors discuss three of the four types of superficial fungal infections in man: tinea nigra palmaris, white piedra, and black piedra. Also considered are several fungi causing tropical or unusual cutaneous disease, including tinea imbricata, favus, some of the geographically distinctive tineas, and Hendersonula toruloidea. Proto thecosis, an opportunistic algal infection, is included for discussion because it is often difficult to distinguish from some of the more arcane fungal diseases.

Unusual Fungal Infections Following Jejunoileal Bypass Surgery

Deep-seated fungal infections with unusual clinical courses developed in three previously healthy patients following jejunoleal bypass surgery. Pulmonary blastomycosis disseminated and then relapsed despite repeated courses of amphotericin B in a 40-year-old man; chronic progressive pulmonary histoplasmosis developed in a 38-year-old nonsmoking man; and histoplasmosis of mediastinal nodes became symptomatic in a 32-year-old man. Cell-mediated immunity was evaluated in two patients; no defects were found. However, male patients were found to be at a significantly higher risk of infection than female patients (3/32 vs 0/101; P less than .02). A significantly higher percentage of prebypass weight was lost by the infected men than the uninfected men (P less than .05). Accelerated weight loss clearly preceded the onset of the infection in two of the patients. Jejunoileal bypass surgery should be regarded as a risk factor for serious fungal infection, especially in men with accelerated weight loss.