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Mycology Cases from Nejm 11/5/2020 OBJECTIVES MYCOLOGY CASES FROM 1. Describe clinical and laboratory findings in cases NEJM caused by fungi. 2. Review typical presentations of the fungi in this Lynda Britton, Ph.D. MLS(ASCP)CM presentation. [email protected] LSUHSC Shreveport 1 2 Case 1 DISSEMINATED FUSARIUM PANCYTOPENIA • 8-year-old boy presented with subcutaneous CBC Result Reference Range nodules Hemoglobin 7.5 g/dL 11.5-14.5 g/dL • 1-week history of fever WBC 200/mm3 5000-11,000/mm3 • 2 months after starting treatment for relapsing B-cell leukemia Platelets 12,000/mm3 150,000-400,000/mm3 • Fevers persisted despite the initiation of broad- spectrum intravenous antibiotic and antifungal treatment 3 4 N Engl J Med 2020; 382:e64 DISSEMINATED FUSARIUM BIOPSY SPECIMEN SHOWED SEPTATE HYPHAE 1 week later subcutaneous nodules developed on the trunk, arms, and legs 5 6 1 11/5/2020 FUSARIUM DIMERUM FUSARIUM DIMERUM • Colonies are salmon-colored, moist and yeast-like, producing very little aerial mycelium • Only slow-growing, clinically significant Fusarium spp. • Macroconidiophores are short, simple (unbranched) or branched • Macroconidia are small in comparison to other species and have 0-3 septa. • Microconidia are absent. • Chlamydoconidia may be present but are usually rare. 7 8 FUSARIUM FUSARIUM • Fusarium DIMERUM • Plant pathogens that cause COMPLEX root and stem rot, vascular wilt, or fruit rot • Cause mycotic keratitis and onychomycosis, especially in burn victims and bone marrow transplant patients; Also leukopenic particularly for those on broad- spectrum antibiotics 9 10 Case 2 Fusarium CANDIDA ESOPHAGITIS • A 72-year-old man presented with a 2- week history of odynophagia • 16 months before diffuse panbronchiolitis treated with macrolide antibiotics • Linear, white, mucosal, plaquelike lesions on the esophagus • Endoscopic findings confirmed by a culture of esophageal brushing positive for Candida albicans 11 12 N Engl J Med 2017; 376:1574 • HIV negative 2 11/5/2020 CANDIDA AT RISK FOR HEAD AND ESOPHAGITIS NECK CANDIDIASIS • Wear dentures • Oral antifungal • Have diabetes therapy • Have cancer • 2 weeks later • Have HIV/AIDS • Take antibiotics or corticosteroids, including inhaled corticosteroids for conditions like asthma • Have dry mouth • Smoke 13 14 GROWTH CHARACTERISTICS OF CANDIDA ALBICANS CANDIDA ALBICANS • Grow on almost all common laboratory media including blood agar, EMB, CNA, PEA, etc. Sabouraud agar with antibacterial antimicrobials (Mycosel) is recommended • Some species of Candida (tropicalis, krusei, and parapsilosis) are susceptible to cycloheximide but C. albicans is not 15 16 CANDIDA ENDOCARDITIS AFTER CANDIDA ALBICANS TAVR • 76-year-old man with congestive heart failure • Worsening shortness of breath • Undergone transcatheter aortic-valve replacement (TAVR) 9 months earlier • Temperature of 39.0°C and grade 5 systolic murmur 17 Case 3 N Engl J Med 2019; 380:e1 18 3 11/5/2020 LABORATORY FINDINGS • WBC 16,000/mm3 • CRP 120 mg/L • 6 consecutive blood cultures positive for Candida parapsilosis ECHOCARDIOGRAM AND VEGETATIONS • Prosthetic-valve endocarditis 19 20 SUSCEPTIBILITY RISK FACTORS FOR INVASIVE CANDIDIASIS • Critical illness with a prolonged intensive care unit stay • Presence of central venous catheters • Use of broad-spectrum antibiotics or total parenteral nutrition • Having hematologic or solid organ malignancy, stem cell transplantation, neutropenia, or recent abdominal surgery (especially in the presence of an anastomotic leak) • Being a pre-term infant with a very low birth weight • Having renal failure or hemodialysis Candida albicans, C. glabrata, C. parapsilosis, C. tropicalis, and C. • Injection drug use krusei 21 22 CANDIDA CANDIDA PARAPSILOSIS PARAPSILOSIS • Glucose yeast extract peptone broth • Ovoid cells, cylindrical cells 20 µm • Cornmeal agar • Pseudohyphae in branched chains 23 24 4 11/5/2020 Case 4 GOMORI METHENAMINE SILVER FUNGAL STAIN ENDOPHTHALMITIS • 34-year-old man with a history of intravenous drug use and infection with HCV • 1-week history of pain and decreased vision in his right eye • Blood cultures and echocardiography negative • Mass adherent to optic nerve • Necrotizing granuloma N Engl J Med 2020; 382:e48 25 26 FUNGAL ENDOPHTHALMITIS FUNGAL ENDOPHTHALMITIS • Completed 6 weeks of oral voriconazole • 2 to 15% of all endophthalmitis cases are endogenous • Visual acuity improved to 20/30 • 1% of patients with candidemia develop Candida • Stable at 6-month follow-up visit with no endophthalmitis evidence of recurrence. • Candida species most common cause of endogenous infections • Rare complication of eye injury or eye surgery • Occurs as a post-surgical complication in approximately 0.1% of all cataract surgeries 27 28 CRYPTOCOCCUS Case 5 NEOFORMANS MENINGOENCEPHALI TIS • A 36-year-old man, sexually active MSM • 2-week history of fever, headache, drowsiness, and photophobia • Opening pressure on lumbar puncture was 29, <20 cm GRAM STAIN AND INDIA INK • HIV viral load was 300,000 copies/ml • CD4+ count was 7N cells/µL Engl J Med 2018; (reference 379:281 range, 500 to 29 30 1450) 5 11/5/2020 LABORATORY FINDINGS • Liposomal amphotericin B and flucytosine • Resolution of symptoms and CRYPTOCOC • CSF cell count 340 cells/µL (reference range, 0 to negative results on CSF after 2 CUS 10) weeks of treatment NEOFORMAN • 90% mononuclear cells predominantly lymphocytes • Consolidation therapy with S MENINGO- fluconazole ENCEPHALITI • Glucose 46 mg per dL (reference range, 40 to 70 • Antiretroviral therapy S mg per deciliter • Protein 0.80 g/L (reference range, 0.15 to 0.45) • Cryptococcal antigen titer -1:128, 31 32 • CSF culture grew Cryptococcus neoformans CRYPTOCOCCUS NEOFORMANS CRYPTOCOCCUS NEOFORMANS EPIDEMIOLOGY EPIDEMIOLOGY • Incidence is fairly low: many people exposed without • Found commonly in the droppings of fowl, particularly pigeons symptoms who do not contract the disease, but excrete it in their feces • An opportunist that primarily affects those with a • Lives for prolonged periods of time in pigeon droppings if not compromised immune state exposed to sunlight • Humans inhale dust contaminated with pigeon or fowl fecal • Causes respiratory and systemic disease such as material containing the viable yeast forms meningitis 33 34 MOST SUSCEPTIBLE TO CRYPTOCOCCOSIS CRYPTOCOCCUS VIRULENCE FACTOR • Defective cell mediated immunity • AIDS and other immune diseases • Large polysaccharide • Hodgkin's disease capsule that prevents • Lymphomas phagocytosis and the • Leukemia production of antibody • Sarcoidosis • Systemic lupus erythematosis 35 36 6 11/5/2020 CRYPTOCOCCUS DIAGNOSTIC FEATURES OF NEOFORMANS COLONIES C. NEOFORMANS • Mucoid and creamy white • Encapsulated budding yeast • Positive Cryptococcus latex • Cycloheximide is inhibitory to it • Phenoloxidase produced— • Brown/black colonies on bird or niger • Formation of melanin-like seed agar pigments on bird seed agar • Urease positive • Nitrate negative • Susceptible to cycloheximide 37 38 CRYPTOCOCCAL LATEX DISSEMINATED ANTIGEN TEST Case 6 CRYPTOCOCCOSIS • Very sensitive and specific test better than India ink prep • 60-year-old man presented with a 4-week history of • Capsular material is solubilized in the body fluids and can progressive skin lesions. be titered with a specific antiserum • Latex particles are coated with specific rabbit • For the past 6 years, he had been treated for chronic immunoglobulin to Cryptococcus and mixed with dilutions lymphocytic leukemia (CLL) of patient's serum or CSF. • Positive agglutination is diagnostic • CD4+ T-cell count was 20 per cubic millimeter (1%) • Titer for prognosis • Multiple papules located mainly on his face but also on • CSF or serum for detection of early, asymptomatic his shoulders, arms, and legs cryptococcal infection in HIV-infected patients • Higher sensitivity than microscopy or culture. 39 N Engl J Med 2014; 370:1741 40 DISSEMINATED CRYPTOCOCCOSIS 41 42 7 11/5/2020 CANDIDA AURIS IN AN CRYPTOCOC- Case 7 INTENSIVE CARE SETTING COSIS • Reusable skin-surface axillary temperature probes • Rare since • Yeasts persisted despite cleaning with quaternary ammonium compounds HAART: • 70 patients in UK neurosciences intensive care unit decreased • Risk factors: 52 median age 90% • 67% male with lower serum albumin levels (P=0.06) • Case-fatality • Higher body temperature (P=0.08) ratio ~12% • Higher serum sodium levels (P=0.07) • Systemic fluconazole treatment Leading cause of death in HIV in Africa> TB43 N Engl J Med 2019; 380:890-891 44 CANDIDA AURIS C. AURIS •Ist multidrug-resistant species of yeast • Emerging, multidrug-resistant pathogen associated • Hospital-acquired with outbreaks worldwide, often in ICUs • Serious bloodstream infections, wound, ear • 2009 first reported, traced to 2004 • May spread between patients • October 26, 2020: Case count 1,394 • 1 in 4 die: 30--60% of patients infected died • Survive for extended periods on common hospital room surfaces • Difficult to ID 46 IDENTIFICATION OF CANDIDA AURIS • No pseudohyphae • Sometimes aggregates of cells • Grows well at 42ᵒC • MALDI-TOF with high scores • Sequencing the 28s rDNA • Send to CDC AR lab network • Antifungal testing white, pink, red or purple 48 8 11/5/2020 LABORATORY MISIDENTIFICATION OF C. AURIS C. AURIS SUSCEPTIBILITY dentificationMethod Organism C. auris can be misidentified as Vitek 2 YST Candida haemulonii Candida duobushaemulonii • All isolates were resistant to fluconazole (MIC >32 mg/L) API 20C Rhodotorula glutinis (characteristic red color not present) • 30% were nonsusceptible to voriconazole
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