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LIFE Newsletter - Leading International Fungal Education

February 2015

The WHO issues guidelines for the management of HIV-related skin and oral conditions

Skin and mucosal conditions are very common in HIV infected adults and children and are one of the most frequent management issues for healthcare workers caring for HIV patients. Skin and mucosal conditions contribute to high morbidity rates. Conditions such as Kaposi's sarcoma, herpes zoster, papular pruritic eruptions and severe Candidosis are characteristically found with HIV. The WHO has identified 10 skin and mucosal infections based on the burden of disease and developed guidelines for their treatment.
Oral candida
The conditions covered include the fungal conditions: oral candidosis, seborrhoeic dermatitis, eosinophilic folliculitis and tinea infections and the non-fungal conditions Kaposi sarcoma, popular pruritic eruption, herpes zoster, scabies, mollucscum contagiosum,  Stevens-Johnson syndrome and toxic epidermal necrolysis.



WHO treatment guidelines
for skin & oral HIV associated conditions. More information


NEWS

Emergence of Coccidioidomycosis in Washington State

Coccidioidomycosis, also called “Valley Fever,” is endemic to the southwestern United States and parts of Mexico and Central and South America. Thousands of cases are reported each year in the U.S. mostly from Arizona and California. Recently, coccidioidomycosis cases have been recognized in Washington State, far north of Coccidioides’ known geographical range. Epidemiologic and laboratory data, including whole genome sequencing results, indicate that several cases were acquired in south-central Washington. 

The first three coccidioidomycosis cases attributed to exposures in Washington are described in the publication by Marsden-Haug (2013) in Clinical Infectious Diseases (CID). The first identified case occurred in June 2010 in a 12-year-old male whose only travel outside of the Pacific Northwest was to Santa Maria, California two years before his illness. He presented with chest pain and was initially hospitalized for bacterial pneumonia, but Coccidioides was cultured from his pleural fluid upon re-admission. In July 2010, a 15-year-old male sustained knee lacerations from a vehicle accident in south-central Washington and developed primary cutaneous coccidioidomycosis at the injury site. Coccidioides Skin scrapings from a cutaneous lesion mounted in 10% KOH and Parker ink, showing characteristic endosporulating spherules (sporangia) of Coccidioides immitis. Image: David Ellis, Mycology online.
The third case described in the CID report was a 58-year-old construction worker who developed culture-confirmed coccidioidal pneumonia in May 2011 which progressed to meningitis in March 2012. His only travel to known endemic areas was a plane change in Arizona three to five years earlier.
The reasons for the apparent emergence of Coccidioides far outside its known range are not entirely clear but could represent sporadic environmental distribution of the organism or under-recognition of the disease. Retrospective analyses of coccidioidomycosis cases in animals further support the hypothesis that Coccidioides has been established in Washington for some time.
Read full report

A high prevalance of Pneumocystis jirovecii colonisation in HIV patients in
S. Brazil.
 Isolate other vulnerable patients?

Pneumocystis jirovecii causes pneumonia (PcP) in patients with HIV - and carries a  high morbidity and mortality rate. The use of trimethoprim- sulfamethoxazole in conjunction with antiretroviral therapy has greatly reduced the incidence in HIV patients 
A recent study by Pereira et al. demonstrated a high prevalence of Pneumocystis jirovecii colonisation by PCR amongst HIV positive patients who were admitted to hospital for other reasons, over one year in Southern Brazil. A low CD4+ count of < 200cells/ul was more often associated with colonisation, but colonisation was also found in patients with higher CD4+. Colonised individuals are potentially at risk from developing pneumonia, but the conversion rate is uncertain. This data contrasts with a study in Uganda in 2012 where only 6% of HIV positive patients were colonised. 
The high frequency of colonisation amongst hospitalised HIV patients in this study, along with  other evidence suggests a reservoir or source of  P. jirovecii  in the hospital setting - this has implications  for isolating this group of patients from other vulnerable individuals such as transplant patients or those undergoing chemotherapy or similar. More information

Predictors of poor outcome of Talaromyces marneffei infection with HIV in Vietnam

Untreated T. marneffei (formerly Penicilliosis) infection in AIDS is fatal. In this study from Hai Phong in northern Vietnam it was found that both a lack of secondary prophylaxis and anti-retroviral therapy were highly correlated with a poor outcome, and conversely almost all the patients treated with both antiretrovirals and secondary prophylaxis with itraconazole 200mg daily survived for over 3 years. Co-infection with hepatitis C or tuberculosis conferred a worse outcome.
T. marneffei infection accounts for 10% of opportunistic infection in AIDS, after TB, ‘disseminated candidosis’ and Pneumocystis pneumonia, and is much more common in this locality than cryptococcal meningitis.
A new observation was that 25% of the patients presented with Talaromyces infection after starting antiretroviral treatment, usually within 2 months. More Information 

GAFFI delegation highlights India's plight as fungal infection capital of the world

Millions of people in India die needlessly of fungal infection because of poor diagnosis and treatment. Delegates from GAFFI (Global Action Fund for Fungal Infections), met with India’s Health Minister J P Nadda to call for a network of testing laboratories across India and trained clinical staff to help reduce unnecessary deaths.
At the meeting, the Health Minister declared: “GAFFI’s bold attempt to define a clear pathway for improvements in care for patients with serious fungal disease is welcome. The Indian government is committed to improving healthcare for all its citizens and recognises that modest investment in this area will reap large health benefits.” Latest GAFFI statistics in India for fungal asthma are 1.5 million and 23 million rVVC cases per year.
Read more

See more News here


Featured LIFE website section: Chromoblastomycosis

Chromoblastomycosis is a cutaneous and subcutaneous mycosis characterized by the appearance of proliferating chronic skin lesions following traumatic implantation of the fungus. Sites most commonly affected are the lower limbs. Upper limbs and buttocks are also frequently involved. Ear, face, neck and breasts have been reported sporadically. Lesions start as nodule or papule that slowly enlarge becoming verrucose and wart-like. It is a worldwide disease but more common in tropical areas of Africa, Central and S. America, Asia and Australia. This disease is occupational and related with any activity where traumatic injury with contaminated material is frequent as agricultural work Link.
Several melanised (black fungi) fungal species can be the etiologic agents of this disease. The most frequent are:  Fonsecaea pedrosoi and Cladophialophora carrionii.Chromoblastomycosis
Clinical observation is not useful to establish the diagnosis. Skin scrapings or a biopsy should be taken from the lesions. Skin scrapings should be examined using 10% KOH and Parker ink or calcofluor white. Tissue sections should be stained with hematoxylin and eosin, PAS, and silver stains. Observation of rounded sclerotic bodies, planate dividing and with a brown pigment should be seen. Identification of species must be done by culture.
No optimal treatment has been identified but the sooner the diagnosis and treatment is made, the better rate of cure. Many patients look for help after many years of disease evolution. Cryosurgery is a good option when the lesions are small. Itraconazole 200-400 mg/day is another option when the lesions are large. Patients usually improve but complete cure is rare. In addition, many cases require years of treatment, which is highly costly.

More Information ; LIFE website.


Top Diagnostic Tip

Treating Bronchoalveolar lavage samples with Sputasol® reduces galactomannan levels

The current gold standard for IPA diagnosis is galactomannan (GM) determination in bronchoalveolar lavage fluid (BALF) samples. Reported performances of GM evaluation in BALF vary widely. Sensitivities between 40% and 97% and specificities between 73% and 95% using a cut-off of 0.5 optical density index (ODI) have been reported in patients with underlying hematological malignancies.
Mucolytic pretreatment
of viscous samples prior to testing is used as it leads to better homogenity of samples and dithiothreitol is used in many laboratories. Sputasol® (Oxoid Microbiological Products) is a commercially available dithiothreitol containing a liquefying agent for respiratory tract samples It is used, for example in pretreating viscose sputum samples from patients with cystic fibrosis. Using a GM assay immunochromatographic assay - Aspergillus-lateral flow device test (LFD); samples were tested with and without Sputasol® pre treatment. Results indicated that Sputasol significantly lowered GM levels in BALF and altered LFD results causing discoloration of the test.
Article: Prattes J et al, J of Infection 2014

 


Really Important Reviews

Candida boodstream Infection: A clinical microbiology perspective by Julia Pongracz and Katalin Kristof
The role of a clinical microbiology laboratory, is to isolate and identify the correct infective agent and provide reliable susceptibility data quickly to guide antifungal therapy. With the incidence of Candida bloodstream infections rising and a change in the frequency of different sub-species and non albicans species new methods must be developed to enhance accuracy and sensitivity. This review covers all aspects of candida bloodstream infections.


New Developments
Drug-drug interactions APP for antifungal medicines - new APP for healthcare professionals

A new electronic resource for healthcare professionals to check drug interactions is now available as an online database or as a smartphone APP.  Medication safety has never been more important for the effective care of patients. A comprehensive new review has identified almost 2,000 potential or recorded interactions between antifungal agents and other medicines.

app

The Fungal Infection Trust  have partnered with the National Aspergillosis Centre based at University Hospital of Manchester, UK  (UHSM) to cross-reference 529 prescription drugs with eight common antifungal drugs.  In summary, 691 interactions were rated as minor, 919 moderate and 381 severe, there were a total of 1991 recorded interactions. APP logo
Healthcare professionals can check potential interactions with antifungal agents on The Aspergillus Website here and the Smartphone APPs are available to download in both Android and APPLE  stores by searching  for “Antifungal Interactions PRO”. 
This PRO APP follows a simpler APP released for patient use.

CARE app

Educational Tool for Fungal infections

CARE (Continuing Antifungal Research and Education) Fungal KnowledgeBank

CARE is an educational initiative for clinicians, scientist and other healthcare professionals in the field of fungal infections. The CARE Fungal KnowledgeBank APP comprises four interactive training modules offering a comprehensive and logical flow through fungal diseases and their management. This resource was developed through a collaborative partnership between Gilead Sciences Europe Ltd. and the University of Manchester, UK. This APP is available from the iTunes APP Store - for APPLE devices only.



Books

 

Human Pathogenic Fungi: Molecular Biology and Pathogenic Mechanisms: by Derek J. Sullivan and Gary P. Moran Publishers: Caister Academic Press

An excellent reference book for students , scientists and clinicians. "... the coloured diagrams and photographs are so informative and stunning , that I can imagine that some of these will become much used in teaching medical mycology courses ... This is a carefully edited and well-produced reference work that deserves to be widely available in laboratories exploring the molecular biology and pathogenicity mechanisms of human pathogenic fungi". IMA fungus

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Courses

 

The first workshop on antifungal susceptibility testing in the routine laboratory will be held in the Turkish language in Ankara, Turkey, on 28 February 2015. The program can be found here.

ESCMID Postgraduate Education Course on the Diagnosis and Management of Fungal Infections Both in the West and the East. Delhi, India, 19-21 March 2015. More information

Course of Medical Mycology at the Institut Pasteur will be held in Paris, March 30 to April 24, 2015. The course will be taught in English and is aimed to microbiologists (MDs, PhDs and veterinarians) with previous practice in a medical mycology laboratory. The course will be divided into interactive lectures, bench sessions and panel discussions during 4 weeks. Application deadline is Nov. 15, 2014.  For information and registration, click here.

19th Congress of the International Society for Human and Animal Mycology: A Mycology MasterClass 4-8th May 2015, Melbourne, Australia More information

HFP2015, the 6th FEBS Advanced Lecture Course on Human Fungal Pathogens, May 16-22, 2015 La Colle-sur-Loup, France: More info
More courses


Help us evaluate the global burden.

Global burden@LIFE copyright

We are looking for volunteers to assist with estimating the burden of fungal infection in the following countries:
Angola, Bulgaria, Bosnia, Burkina Faso, Cambodia, Central African Rep., Chad, Congo and DRC, Costa Rica, Honduras, Mali, Myanmar, Nicaragua, Panama, Papua New Guinea, Poland, Slovak Republic, Tunisia, Uzbekistan and Venezuela.
 Can you help? Contact us