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Siyao Wu,1,* Ting Guo,2,* Hui Zhang,1 Zhiyi He,1 Jianquan Zhang,3 Wen Zeng1 1Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, 530021, People’s Republic of China; 2Department of Dermatology and Venereology, the First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, People’s Republic of China; 3Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, 518000, People’s Republic of China*These authors contributed equally to this workCorrespondence: Wen Zeng, Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, Guangxi Zhuang Autonomous Region, 530021, People’s Republic of China, Tel +86 18589883694, Email zengwen@stu.gxmu.edu.cnAbstract: Adult-onset acquired immunodeficiency caused by anti-IFN-γ autoantibodies is associated with severe opportunistic infection. Due to lack of specific symptoms and different manifestations, this form of infection can be easily misdiagnosed or overlooked. Herein, we present a case of Nocardia farcinica and Talaromyces marneffei co-infection in a patient with anti-IFN-γ autoantibodies (AIGAs). The patient, a 54-year-old man, presented with a 1-month history of fever, coughing and expectoration, dizziness, headache and gait imbalance. Laboratory workup revealed increased inflammatory markers, negative anti-HIV antibody and a high positive titer of AIGAs. Chest computed tomography (CT) showed multiple patches of high-density shadows in both lungs, and brain enhanced magnetic resonance imaging (MRI) showed an irregular lesion. The patient underwent a craniotomy for resection of the lesion. Pulmonary T. marneffei infection was diagnosed through sputum and bronchoalveolar lavage fluid culture, and brain nocardiosis was confirmed via purulent fluid culture of brain tissue. With regular antibiotic therapy, his symptoms improved and there was no recurrence during 18-month follow-up. This may be the first detailed case report detailing infection with these two distinct pathogens in disparate anatomical locations.Keywords: nocardia, Talaromyces marneffei, adult-onset acquired immunodeficiency, anti-IFN-γ autoantibodies, brain abscess

Suke Xing,1,2 Hui Zhang,2 Ye Qiu,3 Mianluan Pan,1 Wen Zeng,2 Jianquan Zhang1 1Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, 518000, People’s Republic of China; 2Department of Respiratory Medicine, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 3Department of Comprehensive Internal Medicine, the Affiliated Tumour Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of ChinaCorrespondence: Jianquan Zhang, Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518000, Guangdong, People’s Republic of China, Tel +8613978123845, Fax +86755-23482484, Email jqzhang2002@126.comPurpose: To summarize the clinical characteristics, treatment and outcomes of transplant recipients infected with Talaromyces marneffei (TM).Materials and Methods: A retrospective analysis was performed on 2 patients with Talaromycosis marneffei (TSM) and transplants at the First Affiliated Hospital of Guangxi Medical University, and a systematic literature review was conducted simultaneously.Results: This article reported two patients after kidney transplantation who developed fever, cough within 3– 4 months. Their haemoglobin was decreased. Their chest computed tomography (CT) showed nodules. TM was detected in their blood or bronchoalveolar lavage fluid samples by next-generation sequencing (NGS). After antifungal treatment with voriconazole (VOR), one patient worsened, the other patient died. A total of 21 patients with TSM after transplants were reported in the literature review. Fourteen underwent kidney transplantation, 4 underwent liver transplantation, 2 underwent lung transplantation, and 1 underwent bone marrow transplantation. The median time from initiating the postoperative immunosuppressive therapy to the onset of symptoms or disease changes was 18 (0.5– 140) months. Among them, 9 patients developed fever, 7 patients developed cough or expectoration and 4 patients developed dyspnoea. Haemoglobin was decreased in 10 patients. Pulmonary nodules were found in 7 patients. Among the 21 patients, 7 were diagnosed by positive culture, 6 by biopsy, 5 by culture and biopsy. Of the 21 patients, 13 patients improved by antifungal therapy, 8 patients worsened or died. Seven patients who received amphotericin B followed by itraconazole (ITR) therapy all improved. Regarding the use of immunosuppressants in 12 patients, 9 patients had to discontinue or reduce their medications (6 patients improved, 3 patients worsened or died).Conclusion: Patients with TSM after transplant often have disseminated infections, involving the respiratory, hematopoietic and so on. Fever, cough, decreased haemoglobin and pulmonary nodules often occur approximately 18 months after surgery. The combined applications of culture, biopsy, NGS are helpful for an early diagnosis. Antifungal therapy with amphotericin B followed by itraconazole is recommended, and the dosage of the immunosuppressant should be adjusted timely.Keywords: Talaromyces marneffei, Talaromycosis marneffei, transplant recipients, immunosuppressants, antifungal drug

Mengxin Tang,1,2,* Mianluan Pan,1,* Ye Qiu,1 Jie Huang,3 Wen Zeng,2 Jianquan Zhang1 1Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, 518000, People’s Republic of China; 2Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 3Department of Tuberculosis Ward, Nanning Fourth People’s Hospital, Nanning, Guangxi, 530021, People’s Republic of China*These authors contributed equally to this workCorrespondence: Wen Zeng, Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China, Tel +8618589883694, Fax +86771-5350031, Email guigao0302@163.com Jianquan Zhang, Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, 518000, People’s Republic of China, Tel +8613978123845, Fax +86755-23482484, Email jqzhang2002@126.comBackground: Anti-IFN-γ autoantibodies (AIGAs) are closely related to the disseminated infection of multiple pathogens. Mycobacterium phlei (M. phlei) is a nonpathogenic nontuberculous mycobacteria (NTM), and M. phlei infection of the bone is extremely rare. We report a rare case of high-titer AIGAs presenting with Sweet’s syndrome (SS) accompanied by opportunistic coinfection with multiple pathogens during 12 years of follow-up. The patient in this case also developed disseminated M. phlei infection with osteolytic destruction after treatment for SS.Case Presentation: A 68-year-old Chinese woman was admitted to our hospital in August 2009 due to fever and cough with expectoration for 3 months. The patient was successively infected with Klebsiella pneumoniae, herpes zoster virus and Candida. Chest computed tomography (CT) showed recurrent consolidations in different lung fields. After 15 months of antimicrobial treatment, the patient experienced partial recovery. In September 2010, the patient was pathologically diagnosed with SS due to the presence of multiple rashes. After prednisone and thalidomide treatment, the rashes subsided, and the pulmonary lesions had completely absorbed. In May 2011, the patient was diagnosed with disseminated tuberculosis and was administered anti-tuberculosis therapy for 3 months without improvement. NTM was subsequently cultured from her sputum and chest wall pus, and she improved after 20 months of anti-NTM therapy. In March 2016, the patient developed osteolytic destruction of the C7-T2 vertebral bodies with a back abscess. NTM was eventually cultured from the dorsal abscess pus and further identified as M. phlei. High-titer AIGAs were detected in the patient’s serum. After another round of aggressive anti-NTM therapy, the patient was finally cured.Conclusion: Patients with AIGA-associated anti-cytokine autoantibody disease can present with multiple opportunistic infections and SS involving the lung. AIGA-associated immunodeficiency leads to infection with nonpathogenic M. phlei, which is refractory, can cause relapse, and even leads to osteolytic destruction.Keywords: Mycobacterium phlei, sweet’s syndrome, osteolytic destruction, anti-IFN-γ autoantibodies

Zhenming Yang,1,2 Wen Zeng,2 Ye Qiu,3 Guangnan Liu,4 Jianquan Zhang1 1Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, 518000, People’s Republic of China; 2Department of Respiratory Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 3Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 4Department of Respiratory Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530005, People’s Republic of ChinaCorrespondence: Jianquan ZhangDepartment of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-sen University, No. 3025, Shennan Middle Road, Shenzhen, 518000, Guangdong, People’s Republic of ChinaTel +8613978123845Fax +86755-23482484Email jqzhang2002@126.comBackground: Talaromyces marneffei (TM) is the only temperature-biphasic pathogen among Penicillium spp. that causes talaromycosis marneffei (TSM). Clinical manifestations include fever, cough, expectoration, superficial and deep lymph node enlargement, hepatosplenomegaly, subcutaneous nodules, and bone and joint infections. Cases of TSM in Hodgkin lymphoma (HL) patients are uncommon. The clinical manifestations and imaging findings are similar in TSM and HL, which make it difficult for clinicians to distinguish between TSM and HL. Both diseases can present with symptoms, can involve the blood or the respiratory system and can include other symptoms. We report a rare case of HIV-negative nodular sclerosing Hodgkin lymphoma (NSHL) combined with T. marneffei infection to improve clinical knowledge.Case Presentation: The patient was a 51-year-old man who presented with a 1-month history of cough, expectoration, intermittent fever in the afternoon and night, cervical lymph node enlargement, diabetes and previous lung surgery. He had markedly elevated serum inflammatory markers and moderate diffuse lung dysfunction. Chest computed tomography (CT) showed diffuse nodular lesions in both lungs with mediastinal lymph node enlargement. The patient did not respond to antibacterial and diagnostic antituberculosis therapy. After lymph node biopsy and lung culture, we obtained a definite diagnosis of NSLH with T. marneffei infection and administered antifungal therapy. His symptoms improved, and he was discharged for further treatment. Unfortunately, he died of Salmonella sepsis 7 months later.Conclusion: It is rare for NSLH patients to be infected with T. marneffei. Both diseases can present with fever, lymphadenopathy, and hepatosplenomegaly and involve the blood and respiratory system or can cause other symptoms. Clinically, a misdiagnosis or missed diagnosis may occur. A multisite biopsy or culture should be performed to make a definitive diagnosis. Early antifungal therapy combined with standard chemotherapy can achieve satisfactory clinical efficacy.Keywords: Talaromyces marneffei, nodular sclerosing Hodgkin lymphoma, identification, treatment

Lingbo Wang,1,* Ying Zhang,2,* Shixing Liu,1 Na Huang,1 Weiliang Zeng,1 Wenya Xu,1 Tieli Zhou,1 Mo Shen1 1Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People’s Republic of China; 2School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, Zhejiang Province, People’s Republic of China*These authors contributed equally to this workCorrespondence: Mo Shen; Tieli ZhouDepartment of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of ChinaTel +86-577-8668-9885Email shenmo601@163.com; wyztli@163.comBackground: The emergence and spread of linezolid-resistant Enterococcus faecalis (E. faecalis) have emerged as a serious threat to human health globally. Therefore, this study aims to compare the anti-microbic as well as the anti-biofilm activity of linezolid, tedizolid, and radezolid against linezolid-resistant E. faecalis.Methods: A total of 2128 E. faecalis isolates were assessed from the First Affiliated Hospital of Wenzhou Medical University from 2011 to 2019. Antibiotic sensitivity was evaluated using the micro broth dilution method. Oxazolidinone-resistant chromosomal and plasmid-borne genes such as cfr, cfr(A), cfr(B), cfr(C), cfr(D), optrA, and poxtA were detected by PCR and then sequenced to detect the presence of mutations in the domain V of the 23S rRNA and the ribosomal proteins L3, L4, and L22. Conjugation experiments were conducted using the broth method. The inhibition and eradication of biofilm were evaluated through crystal violet staining, whereas the efflux pump activities were detected by agar dilution.Results: Out of 2128 isolated E. faecalis, 71 (3.34%) were linezolid-resistant isolates in which the MICs of tedizolid and radezolid ranged from 1 to 4 μg/mL and 0.5– 1 μg/mL, respectively. The MIC50/MIC90 of tedizolid and radezolid were 4 and 8-fold lower than the linezolid, respectively. Out of 71 resistant isolates, 57 (80.28%) carried optrA, 1 (1.41%) carried cfr, 4 (5.63%) carried optrA and cfr, and 6 (8.45%) carried optrA and cfr(D), with no mutations of 23S rRNA gene and ribosomal proteins L3, L4, and L22. Besides, the transfer rate of the optrA, cfr, and cfr(D) was 17.91%, 0% and 0%, respectively. Radezolid showed more effectiveness in eradicating biofilm (8 × MIC). However, tedizolid was more effective than radezolid and linezolid in inhibiting the biofilm formation (1/4 MIC, 1/8MIC, and 1/16MIC). Additionally, in combination with CCCP, the MICs of radezolid in all linezolid-resistant isolates decreased ≥ 4-fold.Conclusion: Radezolid showed greater antimicrobial activity than tedizolid and linezolid against linezolid-resistant E. faecalis. However, both tedizolid and radezolid showed differential activity on biofilm inhibition, eradication, and efflux pump compared to linezolid. Thus, our study might bring important clinical value in the application of these drugs for resistant pathogenic strains.Keywords: Enterococcus faecalis, linezolid, tedizolid, radezolid, in vitro activity, anti-biofilm activity

Mengxin Tang,1,2,* Jie Huang,3,* Wen Zeng,1,2 Yanmei Huang,4 Yaoqiang Lei,5 Ye Qiu,6 Jianquan Zhang1,2,4 1Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 2Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 3Department of Tuberculosis Ward, Nanning Fourth People’s Hospital, Nanning, Guangxi, 530021, People’s Republic of China; 4Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, 518000, People’s Republic of China; 5Department of Infectious Diseases, Yongning District People’s Hospital, Nanning, Guangxi, 530021, People’s Republic of China; 6Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China*These authors contributed equally to this workCorrespondence: Ye QiuDepartment of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of ChinaTel +8615676192180Fax +86771– 5719573Email yeqiu2013graduated@163.comJianquan ZhangDepartment of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of ChinaTel +8613978123845Fax +86755-23482484Email jqzhang2002@126.comPurpose: Disseminated nontuberculous mycobacterial (DNTM) infection can involve multiple organs, including the lungs, skin and soft tissues and lymph nodes. However, NTM infection leading to osteolysis has been rarely reported. Here, we analyzed the clinical features, osteolytic mechanisms, treatment and prognosis of patients with DNTM disease with osteolytic lesions.Patients and Methods: This retrospective study was conducted between January 1, 2011, and December 31, 2020, at the First Affiliated Hospital of Guangxi Medical University and the Fourth People’s Hospital of Nanning City. Patients who had culture and/or histopathological proof of DNTM disease with osteolytic lesions were included.Results: Ten HIV-negative patients with DNTM disease with osteolytic lesions were enrolled. Five of these patients had underlying diseases. Seven and three of the patients were positive and negative for anti-interferon-γ autoantibodies (AIGAs), respectively. The AIGA positivity rate was 70% (7/10). Ostealgia and anemia were the most common symptoms, followed by fever, emaciation, cough, expectoration, anorexia, subcutaneous abscesses and lymphadenopathy. Leukocyte and neutrophil counts were increased. The most common sites were the vertebrae, sternum, clavicle and ribs, although the femur, ilium, humerus, and scapula were also involved. Radiography and computed tomography (CT) showed moth-eaten or irregular destruction of bone, bone defects, pathological fracture, periosteal proliferation and surrounding abscesses. Emission CT (ECT) bone scans showed significantly increased uptake in many skeletal regions. Positron emission tomography(PET)/CT showed metabolic activity in multiple bones. All patients received anti-nontuberculous therapy, and five underwent surgery. Two died during treatment.Conclusion: DNTM infection of bone and leading to osteolysis usually occurs in patients with AIGA-positive antibodies. DNTM disease with osteolysis is characterized by increased leukocytes and neutrophil counts, focal suppurative granulomas, and multiple areas with moth-eaten or irregular destruction of bone with increased radioactive concentrations. Early diagnosis and timely, effective combination anti-NTM therapy can improve the prognosis.Keywords: HIV-negative, nontuberculous mycobacteria, osteolytic lesion, anti-IFN-γ autoantibodies

Fanhai Lin,1,2,* Zhenming Yang,1,3,* Ye Qiu,4 Wen Zeng,3 Guangnan Liu,5 Jianquan Zhang1 1Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Guangdong, 518000, People’s Republic of China; 2Department of Pulmonary and Critical Care Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016,People’s Republic of China; 3Department of Respiratory Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 4Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 5Department of Respiratory Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530005,People’s Republic of China*These authors contributed equally to this workCorrespondence: Jianquan ZhangDepartment of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, No. 3025, Shennan Middle Road, Shenzhen, 518000, Guangdong, People’s Republic of ChinaTel +8613978123845Fax +86755-23482484Email jqzhang2002@126.comBackground: Talaromyces marneffei is considered to commonly cause infection in individuals with human immunodeficiency virus (HIV) infection. However, the epidemiology of T. marneffei has changed, and an increasing number of HIV-negative but immunodeficient patients are infected with T. marneffei. The mechanisms of T. marneffei infection of HIV-negative hosts are complex and diverse. We report 2 cases of HIV-negative lung cancer with T. marneffei infection and positive anti-interferon-gamma autoantibodies (AIGAs) to provide clinical experience.Case Presentation: We report lung adenocarcinoma combined with T. marneffei infection in HIV-negative patients, and their AIGAs were measured. Both patients were male with a family history of cancer and presented with recurrent fever and cough. The patients were negative for HIV antibodies but positive for AIGAs. Chest computed tomography (CT) showed pulmonary nodules, exudative lesions and solid changes. The patients were diagnosed with lung adenocarcinoma and Talaromycosis marneffei (TSM) by pathological examination and tissue culture. Patient 1 received only antifungal treatment, refused antitumor treatment and died in February 2019, and Patient 2 unfortunately died in April 2019 after antifungal and antitumor treatments.Conclusion: An increasing number of HIV-negative but immunodeficient patients are infected with T. marneffei. The 2 patients in this report had lung cancer and positive AIGAs, causing immunodeficiencies, but the mechanism of T. marneffei infection in such patients is complex. Clinically, we should consider a comprehensive immunological examination to avoid the omission of other immunodeficiencies. We recommend routine testing for AIGA levels in HIV-negative marneffei patients. It is difficult to distinguish between lung cancer and disseminated TSM due to similar clinical characteristics and imaging, and multiple biopsies and cultures of diseased tissue are necessary. Early antifungal treatment and standard antitumor treatment can achieve satisfactory curative effects when a patient has both diseases.Keywords: Talaromyces marneffei, lung adenocarcinoma, adult immunodeficiency, anti-interferon-γ antibodies

Huaiyu Jia,1 Ying Zhang,2 Jianzhong Ye,1 Wenya Xu,1 Ye Xu,1 Weiliang Zeng,2 Wenli Liao,1 Tao Chen,1 Jianming Cao,2 Qing Wu,1 Tieli Zhou1 1Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People’s Republic of China; 2Department of Medical Laboratory Science, School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, Zhejiang Province, People’s Republic of ChinaCorrespondence: Tieli Zhou; Qing WuDepartment of Clinical Laboratory, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of ChinaTel/Fax +86-0577-8668-9885Email wyztli@163.com; wuqing830@163.comBackground: OXA-232-producing carbapenem-resistant Klebsiella pneumoniae (CRKP) has the potential to become the “third epidemic” of carbapenem-resistant Klebsiella strain after KPC-2 and NDM in China. We investigated the first outbreak of CRKP in the First Affiliated Hospital of Wenzhou Medical University.Methods: We collected 610 clinical isolates of CRKP from the First Affiliated Hospital of Wenzhou Medical University between January 2019 and September 2020 and screened them by Polymerase Chain Reaction (PCR). The multilocus sequence typing and pulsed-field gel electrophoresis were used to determine the genetic relatedness of the strains. The antimicrobial susceptibility test was performed to determine the drug resistance of the clinical isolates. The molecular mechanism underlying carbapenem resistance was elucidated by performing PCR and conjugation experiments. The virulence potential of the strains was determined by the string test, detection of virulence-associated genes and capsular serotypes, and Galleria mellonella larval infection model.Results: Between September 2019 and May 2020, 26 OXA-232-producing CRKP were obtained from 12 patients in our hospital. Ten patients were hospitalized in the intensive care units (ICU) and the overall mortality of the inpatients involved in the outbreak was 50% (6/12). Epidemiological investigations reported that all the OXA-232-producing CRKP strains belonged to the sequence type ST15 and can be clonally transmitted among the inpatients in the ICU. All the strains had low virulence and were resistant to commonly used clinical antibiotics except for ceftazidime/avibactam, colistin, and tigecycline. The OXA-232-producing CRKP was sensitive to triclosan and chlorhexidine, and its eradication from our hospital can be achieved by the use of disinfectants in the ICU.Conclusion: In our study, OXA-232-producing CRKP isolates appeared to be clonally transmitted and the sequence type ST15 was responsible for the outbreak. Therefore, effective measurements for the infection control of CRKP are urgently needed to prevent its epidemic in the nearby region in the future.Keywords: Klebsiella pneumoniae, carbapenem-resistance, virulence, OXA-232, outbreak

Wen Zeng,1,2 Ye Qiu,1,2 Mengxin Tang,1,2 Hui Zhang,2 Mianluan Pan,1 Shudan Tang,2 Jianquan Zhang1 1Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, 518000, People’s Republic of China; 2Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of ChinaCorrespondence: Jianquan ZhangDepartment of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, 518000, People’s Republic of ChinaTel +8613978123845Fax +86755-23482484Email jqzhang2002@126.comAbstract: A high titer of neutralizing anti-interferon-γ autoantibodies can cause immunodeficiency associated with severe or disseminated infections caused by Talaromyces marneffei in human immunodeficiency virus-negative patients. Herein, we reported a rare case of disseminated Talaromyces marneffei and Burkholderia cepacia infection. The patient’s lungs, lymph nodes, and bronchi were involved, and he had neck abscesses and osteomyelitis. We measured the neutralizing anti-interferon-γ autoantibodies in the peripheral blood and found that the patient had a persistently high positive titer. Despite aggressive treatment, the patient developed disseminated intravascular coagulation and died. Thus, high-titer nAIGAs may be associated with multiple opportunistic, persistent and disseminated infections.Keywords: Burkholderia cepacia, Talaromyces marneffei, adult immunodeficiency, neutralizing anti-interferon-γ autoantibodies

Ying Zhang,1 Lingbo Wang,2 Cui Zhou,2 Yishuai Lin,1 Shixing Liu,2 Weiliang Zeng,1 Kaihang Yu,1 Tieli Zhou,2 Jianming Cao1 1Department of Medical Lab Science, School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, Zhejiang Province, 325035, People’s Republic of China; 2Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325035, People’s Republic of ChinaCorrespondence: Jianming CaoDepartment of Medical Lab Science, School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, Zhejiang Province, People’s Republic of ChinaTel +86-0577-88069595Email wzcjming@163.comTieli ZhouDepartment of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People’s Republic of ChinaTel +86-0577-86689885Email wyztli@163.comPurpose: Multidrug-resistant (MDR) Enterococcus faecium is an important nosocomial pathogen causing urinary tract infection, and the reapplication of nitrofurantoin (NIT) in the clinic has attracted great attention. This study aims to explore the NIT resistance mechanisms and epidemiological characteristics of E. faecium clinical isolates.Patients and Methods: A total of 633 E. faecium clinical isolates was obtained from urine samples in a clinical teaching hospital during 2017– 2018. Among them, 40 NIT-resistant strains, and a similar number of -intermediate and -susceptible strains were isolated. The minimum inhibitory concentrations (MICs) of NIT were detected by agar dilution method. The prevalence and mutations of nitroreductase-encoding genes ef0404 and ef0648 were explored by polymerase chain reaction (PCR), followed by efflux pump inhibition test and quantitative real-time PCR (qRT-PCR) to investigate the resistance mechanisms of NIT. Furthermore, the epidemiological characteristics were detected by multilocus sequence typing (MLST).Results: The carrying rates of nitroreductase in NIT-susceptible, -intermediate, and -resistant isolates were 100%, 50%, and 20%, respectively. After exposure to the efflux pump inhibitor, the MIC of 12 E. faecium decreased by ≥ 4-fold. However, the efflux pump genes efrAB, emeA, and oqxAB were not overexpressed in NIT-resistant E. faecium isolates. Moreover, MLST analysis revealed that all the NIT-resistant isolates belonged to CC17, of which 30 (75%) were associated with ST78.Conclusion: This study has established for the first time that the absence of EF0404 and EF0648 is the main mechanism of NIT resistance in E. faecium. Our findings are likely to fill the knowledge gap pertaining to the NIT resistance mechanism in E. faecium and provide important insights for molecular epidemiological characteristics analysis.Keywords: Enterococcus faecium, nitrofurantoin, nitroreductase, resistance mechanism, epidemiology

Xiangkuo Zheng,1,* Renchi Fang,2,* Chong Wang,3 Xuebin Tian,4 Jie Lin,1 Weiliang Zeng,4 Tieli Zhou,1 Chunquan Xu1 1Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, People’s Republic of China; 2Department of Laboratory Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, People’s Republic of China; 3Department of Laboratory Medicine, Qingdao Municipal Hospital, Qingdao, 266000, People’s Republic of China; 4School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, 325035, People’s Republic of China*These authors contributed equally to this workCorrespondence: Chunquan Xu; Tieli ZhouDepartment of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, People’s Republic of ChinaTel +86-577-5557-9725; +86-577-8668-9885Email 417242374@qq.com; wyztli@163.comBackground: Staphylococcus aureus (S. aureus) is a major contributor to nosocomial and community-acquired infections. S. aureus small colony variants (SCVs) which changed in relevant phenotype have made more limited and difficult for therapeutic options against S. aureus infections increasingly. Rifampicin is considered as the “last-resort” antibiotic against S. aureus. Our study investigated resistance profiles and biological characteristics of rifampicin-resistant S. aureus SCVs.Methods: We collected S. aureus SCVs that were selected from 41 rifampicin-resistant clinical isolates. Then, biological characteristics, resistance spectrum, and rifampicin resistance mechanisms of tested S. aureus SCVs and corresponding parental strains were investigated by classic microbiological methods, agar dilution method, polymerase chain reaction (PCR). Moreover, the fitness cost of S. aureus SCVs, including growth, biofilm formation ability, and virulence profile, was also determined by bacterial growth curve assay, biofilm formation assay, and Galleria mellonella infection model.Results: There were three S. aureus SCVs (JP310 SCVs, JP1450 SCVs, JP1486 SCVs) that were selected from 41 rifampicin-resistant S. aureus. S. aureus SCVs colonies were tiny, with decreased pigmentation, and the hemolysis circle was not obvious compared with corresponding parental strains. And SCVs could not be restored to normal-colony phenotype after hemin, menaquinone, or thymidine supplementation. Different rpoB mutations occurred in JP1486 SCVs. Antimicrobial susceptibility testing revealed MICs of SCVs were higher than corresponding parental strains. Besides, the growth ability and virulence of SCVs were lower, and biofilm formation ability of which increased compared with parental strains.Conclusion: S. aureus SCVs share the rifampicin resistance mechanisms with parental strains, although there were some differences in the position of rpoB mutations. Moreover, we found that the biological characteristics of SCVs were significantly different from corresponding parental strains. In contrast, decreased susceptibility to other antibiotics of SCVs was observed during phenotype switch. Furthermore, SCVs incur the fitness cost.Keywords: Staphylococcus aureus, small-colony variant, rifampicin resistance, resistance profile, biological characteristic

Jingshan Wei,1 Ye Qiu,1 Wen Zeng,1 Mianluan Pan,1 Jianquan Zhang1,2 1Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, Pepole’s Republic of China; 2Department of Respiratory and Critical Care Medicine, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, Pepole’s Republic of ChinaCorrespondence: Jianquan ZhangDepartment of Respiratory and Critical Care Medicine, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, Pepole’s Republic of ChinaTel +86 139 7812 3845Fax +86 0771 535 0031Email jqzhang2002@126.comPurpose: Talaromyces marneffei is a highly invasive fungus, causing fatal mycosis in patients with or without HIV in Southeast and Eastern Asia. However, its presence in patients with systemic lupus erythematosus is rarely reported.Methods: We reported two SLE patients infected by T. marneffei and reviewed other patients reported in the English literature. All cases were pooled for analysis.Results: Eleven patients with SLE infected with T. marneffei infection were identified, including the two presented here. Three were male and eight were female; all were HIV negative. All the patients, except two where data were missing, had received immunosuppressants before T. marneffei infection. The main clinical features included fever, cough, lymph node enlargement, gastrointestinal symptoms, and rash. Five patients were misdiagnosed as having SLE exacerbation. T. marneffei was detected via culture or histopathologic analysis, with the fungus most commonly found in the blood. Seven of the 11 patients were successfully treated by timely antifungal therapy with concomitant SLE control, while four patients who did not receive antifungal therapy died.Conclusion: T. marneffei infection should be excluded when SLE patients, especially if on long-term immunosuppressants, present with fever, cough, lymph node enlargement, gastrointestinal symptoms, and rash. Controlling the lupus and timely antifungal treatment can improve the outcomes of SLE patients with T. marneffei infection.Keywords: Talaromyces marneffei, systemic lupus erythematosus, immunosuppressant

Ye Xu,1 Xiangkuo Zheng,2 Weiliang Zeng,2 Tao Chen,1 Wenli Liao,1 Jiao Qian,1 Jie Lin,1 Cui Zhou,1 Xuebin Tian,2 Jianming Cao,2 Tieli Zhou1 1Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People’s Republic of China; 2Department of Medical Laboratory Science, School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, Zhejiang Province, People’s Republic of ChinaCorrespondence: Jianming Cao; Tieli Zhou Tel +86-577-88069595; +86-577-86689885Email wzcjming@163.com; wyztli@163.comBackground: Heteroresistance is a phenomenon that occurs in all bacteria and can cause treatment failure. Yet, the exact mechanisms responsible for heteroresistance still remain unknown. The following study investigated the mechanisms of imipenem-heteroresistance and -resistance in Pseudomonas aeruginosa clinical isolates from Wenzhou, China.Methods: Imipenem resistance was detected by the agar dilution method; heteroresistance was determined by population analysis profiles. Biofilm formation assay and modified carbapenem inactivation methods were also performed. Polymerase chain reaction (PCR) was conducted to detect oprD, and quantitative real-time PCR was used to determine expression levels of oprD, ampC and four efflux pump coding genes (mexB, mexD, mexE and mexY).Results: Six imipenem-heteroresistant and -resistant P. aeruginosa isolates were selected respectively. Deficient oprD was detected in all resistant isolates and two heteroresistant isolates. No strains produced carbapenemases. Expression levels of oprD were down-regulated in heteroresistant isolates. Transcription levels of the mexE and mexY were significantly increased in all heterogeneous subpopulations compared with their respective native ones. Compared with the susceptible group, increased mean relative expression levels of mexE and mexY or the decreased mean relative expression levels of oprD were observed in the resistant group (P < 0.05), whereas transcription levels of the mexB and mexD remained unchanged.Conclusion: Down-regulation of oprD contributed to the resistance and heteroresistance of imipenem in our P. aeruginosa clinical isolates. In addition, the marginal up-regulation of efflux systems may indirectly affect imipenem resistance. Contrarily, defective oprD was less common in our experimental heteroresistant strains than resistant strains.Keywords: Pseudomonas aeruginosa, imipenem, resistance, heteroresistance, molecular mechanism, oprD

Yanping Tang,* Hui Zhang,* Haiguang Xu, Wen Zeng, Ye Qiu, Caimei Tan, Shudan Tang, Jianquan Zhang Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China*These authors contributed equally to this workCorrespondence: Jianquan ZhangDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of ChinaTel/ Fax +86 7715350031Email jqzhang2002@126.comBackground: Dendritic cells (DCs) with both proinflammatory and tolerogenic properties have been implicated in modulation of CD4+ T cell responses in many fungal diseases. However, the role of DC in the context of Talaromyces marneffei (T. marneffei) infection has not been determined. In this study, we aimed to study the effect of the yeast form of T. marneffei yeasts on DCs, as well as the role of DCs in modulating T helper 17 (Th17) and regulatory T (Treg) cell responses to the pathogen.Methods: Mouse bone marrow-derived DCs were stimulated with T. marneffei yeasts for 24 h. Frequencies of CD80 and CD86 expression on DCs and the levels of IL-6, IL-10 and TGF-β in the culture supernatant of yeast-stimulated DCs were detected by flow cytometry and ELISA, respectively. In co-culture experiments, CD4+ T lymphocytes of mice were isolated from the spleen using magnetic beads and co-cultured with T. marneffei yeasts, with or without DCs for 24 h. The proportions of Th17 and Treg cells in co-culture were detected by flow cytometry. The mRNA levels of RORγt and Foxp3 were detected by RT-PCR. Levels of IL-10 and TGF-β in the co-culture supernatant were detected by ELISA.Results: The expressions of CD80 and CD86 on DCs were increased, as well as IL-6, IL-10 and TGF-β levels in the culture supernatant of T. marneffei-stimulated DCs were higher than those in DCs cultured without T. marneffei. In co-culture experiments, in the presence of DCs, T. marneffei promoted Treg expansion and Foxp3 up-regulation but limited Th17 and downregulated RORγt. Levels of IL-10 and TGF-β were higher in the co-culture containing DCs than without DCs.Conclusion: Our findings demonstrated that the interaction between DCs and T. marneffei could promote Treg expansion but not Th17 generation. These findings provide a mechanism by which DCs may promote immune tolerance in T. marneffei infection.Keywords: dendritic cells, Talaromyces marneffei, Th17 cells, Treg cells

Mianluan Pan, Ye Qiu, Wen Zeng, Shudan Tang, Xin Feng, Jingmin Deng, Xuan Wei, Zhiyi He, Jianquan Zhang Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of ChinaCorrespondence: Jianquan ZhangDepartment of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi, People’s Republic of ChinaTel +86 139 7812 3845Fax +86 0771 535 0031Email jqzhang2002@126.comPurpose: Talaromyces marneffei (T.M) is an intracellular opportunistic fungus that causes invasive mycosis in patients with or without human immunodeficiency virus (HIV) infection. Hemophagocytic lymphohistiocytosis (HLH) caused by T.M infection is extremely rare. Here, we analyzed the clinical features, immune mechanisms, treatment, and prognosis related to this comorbidity.Patients and Methods: This retrospective study was conducted between August 2012 and February 2019 at multiple research centers. Patients who presented with culture and/or histopathological proof of talaromycosis-associated HLH were included.Results: HIV-negative patients (n = 126) were enrolled. Of nine patients with T.M infection combined with secondary HLH, six were preschool children (five boys and one girl), and three were adults (two men and one woman). Seven of these nine had underlying diseases or recurrent infections. The most common symptoms were fever, anemia, hypoproteinemia, cough, weight loss, oral thrush, lymphadenopathy, hepatomegaly, splenomegaly, digestive symptoms, joint pain, and dyspnea. All patients showed reduced hemoglobin concentrations and platelet numbers. Liver dysfunction, hyperferritinemia, elevated lactate dehydrogenase, and low natural killer cell numbers were observed. Eight of nine patients received antifungal therapy, one patient did not receive therapy, and two of nine patients received anti-HLH therapy. Four died during treatment.Conclusion: T.M fungemia associated with HLH was related to high mortality. Once diagnosed, timely and effective antifungal treatments and supportive care are essential.Keywords: Talaromyces marneffei, hemophagocytic lymphohistiocytosis, human immunodeficiency virus, prognosis