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Bloodstream infections due to yeast species especially Candida spp. have been reported to be important healthcare associated infections with high mortality and morbidity rates. Candidemia causes prolonged hospital stays as well as increased cost. In order to prevent or treat these life-threatening bloodstream infections successfully, nationwide epidemiological data should be available about the etiological agents of these infections. Multi-centre national epidemiological data on yeast bloodstream infections in Turkey is lacking. A retrospective study was designed and data from six different centres in Turkey between 2011 and 2016 years were gathered and analysed for the distribution and frequency of yeast species in order to assist clinicians in their choice of early and appropriate antifungal therapy. All laboratories used automated blood culture systems for the isolation of blood strains. All the participating centres performed the identification of their own isolates by conventional methods using germ tube test, morphology on corn meal agar with tween 80 and chromogenic media and the identification was confirmed by API 20C AUX, API ID 32C or matrix-assisted laser desorption/ionization time of flight mass spectrophotometry (MALDI-TOF MS) systems. The analysis of the results was performed on the basis of intensive care units (ICUs), other inpatient clinics (OICs) and totally all clinics (ACs). Totally 2547 yeast isolates were determined from six participating centres during six years. According to the total ACs results, Candida albicans was the most prevalent species (43.1%), followed by Candida parapsilosis complex (29.1%), Candida glabrata (10.1%), Candida tropicalis (7.5%), Candida krusei (2.4%) and Candida kefyr (1.6%) and the remaining (6.2%) of them consisted of other yeast species. The distribution of the Candida species did not show statistically significant difference between the years, however the increase of C.parapsilosis complex in 2016 was statistically significant, (p= 0.02). During the study period, totally 1054 yeast isolates were obtained from the ICUs of the centres. C.albicans predominated with 476 (45.2%) isolates and C.parapsilosis complex (28.7%), C.glabrata (10.7%) and C.tropicalis (7.3%) were the other leading species in ICUs. Among 1493 isolates of the OICs of six centres participated in the study, C.albicans was the most prevalent species with 622 (41.7%) isolates. The other frequent species of OICs were C.parapsilosis complex (29.5%), C.glabrata (9.6%) and C.tropicalis (7.6%) resembling ICU results. It can be concluded that C.albicans is still the leading cause of bloodstream infections in the six different centres located in various geographical areas of Turkey.

Cryptococcus neoformans is generally observed with immunosuppressive conditions. Rarely, it may be seen in immunocompetent individuals and presented with non-specific conditions. We described an immunocompetent case of cryptococcal meningitis presented with multiple cerebral infarcts. Despite the late diagnosis and emergence of hydrocephalus during treatment, the patient was recovered without any sequelae. In immunocompetent patients, the conventional diagnostics tests may be negative because of the low fungal load. If it is available, the Biofire FilmArray meningitis panel has high sensitivity and specificity for diagnosis. (C) 2021 The Authors. Published by Elsevier Ltd.

The goal of most studies published on sand contaminants is to gather and discuss knowledge to avoid faecal contamination of water by run-offs and tide retractions. Other life forms in the sand, however, are seldom studied but always pointed out as relevant. The Mycosands initiative was created to generate data on fungi in beach sands and waters, of both coastal and freshwater inland bathing sites. A team of medical mycologists and water quality specialists explored the sand culturable mycobiota of 91 bathing sites, and water of 67 of these, spanning fromthe Atlantic to the EasternMediterranean coasts, including the Italian lakes and the Adriatic, Baltic, and Black Seas. Sydney (Australia) was also included in the study. Thirteen countries took part in the initiative. The present study considered several fungal parameters (all fungi, several species of the genus Aspergillus and Candida and the genera themselves, plus other yeasts, allergenic fungi, dematiaceous fungi and dermatophytes). The study considered four variables that the team expected would influence the results of the analytical parameters, such as coast or inland location, urban and non-urban sites, period of the year, geographical proximity and type of sediment. The genera most frequently found were Aspergillus spp., Candida spp., Fusarium spp. and Cryptococcus spp. both in sand and in water. A site-blind median was found to be 89 Colony-Forming Units (CFU) of fungi per gram of sand in coastal and inland freshwaters, with variability between 0 and 6400 CFU/g. For freshwater sites, that number was 201.7 CFU/g (0, 6400 CFU/g (p = 0.01)) and for coastal sites was 76.7 CFU/g (0,3497.5 CFU/g). For coastalwaters and allwaters, themedianwas 0 CFU/ml (0, 1592 CFU/ml) and for freshwaters 6.7 (0, 310.0) CFU/ml (p < 0.001). The results advocate that beaches should bemonitored for fungi for safer use and better management. Highlights: Fungi are missing from water and sand health protection regulatory parameters; Both sand and water should be monitored for fungi; The median value of 89 CFU/g of all fungi may serve as a reference for sand regulation; Candida albicans, dermatophytes, endemic fungi and other fungi should be considered; Fungal analysis of water needs more data before reference values can be established. Acknowledgements: A. Abdillah, M. C. Esposto, J. Kabtani, K. Sarioglou, P. E. Verweij and F. Vieira for their collaboration in this study; the European Confederation of Medical Mycology for a seeding grant; the International Society for Human and Animal Mycology for some financial support; financial support from CESAM (UID/AMB/50017-POCI-01-0145-FEDER-007638) and CITAB (UID/AGR/04033/2019), via FCT/MCTES, from national funds (PIDDAC), cofounded by FEDER, (PT2020 Partnership Agreement and Compete 2020) and an NHMRC APP1121936 to W. Meyer; National and Kapodistrian University of Athens, Greece, Special Accounts for Research Grants (SARG K.A. 70/3/6915). info:eu-repo/semantics/publishedVersion

Fundamental niche prediction of Cryptococcus neoformans and Cryptococcus gattii in Europe is an important tool to understand where these pathogenic yeasts have a high probability to survive in the environment and therefore to identify the areas with high risk of infection. In this study, occurrence data for C. neoformans and C. gattii were compared by MaxEnt software with several bioclimatic conditions as well as with soil characteristics and land use. The results showed that C. gattii distribution can be predicted with high probability along the Mediterranean coast. The analysis of variables showed that its distribution is limited by low temperatures during the coldest season, and by heavy precipitations in the driest season. C. neoformans var. grubii is able to colonize the same areas of C. gattii but is more tolerant to cold winter temperatures and summer precipitations. In contrast, the C. neoformans var. neoformans map was completely different. The best conditions for its survival were displayed in sub-continental areas and not along the Mediterranean coasts. In conclusion, we produced for the first time detailed prediction maps of the species and varieties of the C. neoformans and C. gattii species complex in Europe and Mediterranean area.

WOS: 000485661700047, PubMed: 30980958, Objectives: This study investigated the antifungal resistance rates of isolates from candidaemia patients in 12 tertiary-care centres in Turkey. Methods: A total of 1991 Candida spp. isolates from 12 centres isolated from 1997-2017 were included in the study. Species/species complex (SC) identification was performed using conventional methods in all centres, occasionally accompanied by MALDI-TOF/MS. Antifungal susceptibility testing was performed for amphotericin B, fluconazole, itraconazole, posaconazole, voriconazole and micafungin (as echinocandin class representative) using the CLSI microdilution method. Resistance rates were determined according to CLSI clinical breakpoints (CBPs). For drugs and species with undetermined CBPs, epidemiological cut-off values were used for wild-type (WT)/non-WT categorisation. Results: No or low rates of resistance were detected in general for tested Candida spp. isolates. Specifically, overall resistance to fluconazole in isolates of Candida parapsilosis SC and Candida glabrata SC were 7.7% and 0.9%, respectively. Resistance rates for C. parapsilosis SC varied extensively from one center to other (0-47.1%). Importantly, no echinocandin resistance was detected. Rates of non-WT isolates were also generally low: fluconazole against Candida lusitaniae, 4.3%; posaconazole against C. parapsilosis SC, 3.5%; posaconazole against Candida krusei, 1.9%; and voriconazole against C. glabrata SC, 0.5%. Conclusion: This is the first multicentre report of antifungal resistance rates among candidaemia isolates in Turkey, suggesting low resistance rates in general. Due to varying rates of fluconazole resistance in C. parapsilosis SC isolates that was detected at remarkably high levels in some centres, further studies are warranted to explore the source, clonal relatedness and resistance mechanisms of the isolates. (C) 2019 International Society for Antimicrobial Chemotherapy. Published by Elsevier Ltd. All rights reserved., PfizerPfizer [WS776070], This study was supported by an Investigator-Initiated Research grant from Pfizer [WS776070 to SA-A]. The sponsor had no role in the study design, data collection or analysis, or manuscript preparation and submission.

Invasive candidiasis (IC) is a life-threatening fungal infection with high morbidity and mortality. In this study, we aimed to investigate the Candida species distribution and antifungal drug susceptibility and to identify the risk factors associated with IC mortality in children. We conducted a retrospective, single-centre study of paediatric IC in patients from a tertiary care hospital in Turkey between January 2013 and February 2019. A total of 56 Candida isolates underwent antifungal susceptibility testing performed by Sensititre YeastOne YO10 panel, and the demographic and clinical data of 65 patients were examined during the study period. The most commonly isolated species was Candida albicans in 30 patients (46%), followed by C. parapsilosis in 25 patients (38%) and C. tropicalis in three patients (5%). According to the antifungal drug susceptibility testing, C. albicans was fully susceptible to fluconazole and the other antifungal agents (100%). None of the isolates displayed resistance to anidulafungin, micafungin, flucytosine, posaconazole, voriconazole or itraconazole. There were low rates of resistance to fluconazole (1.8%), caspofungin (1.8%) and micafungin (1.8%). In addition, 5.3% of the Candida isolates were susceptible in a dose-dependent manner to itraconazole, 3.6% were susceptible to voriconazole and fluconazole and 1.8% were susceptible to anidulafungin. The mortality rate of IC was 15.4%. Thrombocytopenia after IC treatment was significantly associated with mortality in the multivariate analysis. These results, which help determine the species distribution, antifungal susceptibility patterns and risk factors for mortality, could make a significant contribution to the management of these challenging infections, including choosing appropriate empirical antifungal therapy.

Thirty-six patients with candidemia and 37 control patients were included consecutively to determine the characteristics of candidemia episodes. The patients with candidemia had higher mortality with higher Sequential Organ Failure Assessment scores and frequency of use of a central venous catheter, total parenteral nutrition, and broad-spectrum antibiotics; chronic renal failure with replacement therapy; and longer stay in an intensive care unit. Candida albicans was the predominant species followed by Candida glabrata, Candida tropicalis, and Candida parapsilosis. All isolates of C glabrata were itraconazole-resistant.

PubMedID: 30953839 A total of 476 European isolates (310 Cryptococcus neoformans var. grubii, 150 C. neoformans var. neoformans, and 16 C. gattii species complex) from both clinical and environmental sources were analyzed by multi-locus sequence typing. Phylogenetic and population genetic analyses were performed. Sequence analysis identified 74 sequence types among C. neoformans var. neoformans (VNIV), 65 among C. neoformans var. grubii (56 VNI, 8 VNII, 1 VNB), and 5 among the C. gattii species complex (4 VGI and 1 VGIV) isolates. ST23 was the most frequent genotype (22%) among VNI isolates which were mostly grouped in a large clonal cluster including 50% of isolates. Among VNIV isolates, a predominant genotype was not identified. A high percentage of autochthonous STs were identified in both VNI (71%) and VNIV (96%) group of isolates. The 16 European C. gattii species complex isolates analyzed in the present study originated all from the environment and all belonged to a large cluster endemic in the Mediterranean area. Population genetic analysis confirmed that VNI group of isolates were characterized by low variability and clonal expansion while VNIV by a higher variability and a number of recombination events. However, when VNI and VNIV environmental isolates were compared, they showed a similar population structure with a high percentage of shared mutations and the absence of fixed mutations. Also linkage disequilibrium analysis reveals differences between clinical and environmental isolates showing a key role of PLB1 allele combinations in host infection as well as the key role of LAC1 allele combinations for survival of the fungus in the environment. The present study shows that genetic comparison of clinical and environmental isolates represents a first step to understand the genetic characteristics that cause the shift of some genotypes from a saprophytic to a parasitic life style. © 2019 Elsevier Inc. Fundação para a Ciência e a Tecnologia National and Kapodistrian University of Athens APP1031943 70/3/6915, 70/4/5905 POCI-01-0145-FEDER-006958, UID/AGR/04033/2019 We thank Dr. Kwon Chung and Prof. Dromer for contribution in the critical reading of the manuscript. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. W Meyer and S Lockhart were supported by an NH&MRC grant # APP1031943 . AC Sampaio was supported by Fundação para a Ciência e Tecnologia and FEDER/COMPETE/POCI provided to CITAB under the projects POCI-01-0145-FEDER-006958 and UID/AGR/04033/2019. A Velegraki was supported by SARG K.A.70/4/5905 and 70/3/6915, National and Kapodistrian University of Athens and the Bodosakis Foundation , Athens, Greece.

Ozet Enfeksiyon sant uygulamalarinda halen en sik gorulen komplikasyondur. Mantar enfeksiyonlari nadir olmakla birlikte ciddi morbidite ve mortalite ile iliskilidir. Premature yenidoganlarda ve beyin ameliyatlarindan sonra bu risk artar. Bu makalede, tedavi sirasinda artmis MIC degeri nedeniyle amphoterisin B tedavisine cevap vermeyip vorikonazol ile flusitozin tedavisine cevap veren beyin omurilik sivisi (BOS)’da tekrarlayan Candida albicans uremeleri ile giden sant enfeksiyonlu bir olgu sunulmustur. (J Pediatr Inf 2015; 9: 181-4) Anahtar kelimeler: Candida albicans, sant enfeksiyonu, amfoterisin B, minimal inhibisyon konsantrasyonu Abstract Infection is still the most common complication of shunt procedures in children. However fungal infection is considered to be rare, it is also associated with significant morbidity and mortality. The risk is increasing in premature neonates and after neurosurgery. Herein, we present a preterm neonate with persistant Candida albicans cerebrospinal fluid (CSF) shunt infection that was unresponsible to amphotericin B treatment due to increased minimal inhibitory concentration (MIC) during the therapy period and later which was treated by voriconazole plus flucytosine. (J Pediatr Inf 2015; 9: 181-4)

In order to elucidate the distribution of Cryptococcus neoformans and C. gattii in the Mediterranean basin, an extensive environmental survey was carried out during 2012-2015. A total of 302 sites located in 12 countries were sampled, 6436 samples from 3765 trees were collected and 5% of trees were found to be colonized by cryptococcal yeasts. Cryptococcus neoformans was isolated from 177 trees and C. gattii from 13. Cryptococcus neoformans colonized 27% of Ceratonia, 10% of Olea, Platanus and Prunus trees and a lower percentage of other tree genera. The 13 C. gattii isolates were collected from five Eucalyptus, four Ceratonia, two Pinus and two Olea trees. Cryptococcus neoformans was distributed all around the Mediterranean basin, whereas C. gattii was isolated in Greece, Southern Italy and Spain, in agreement with previous findings from both clinical and environmental sources. Among C. neoformans isolates, VNI was the prevalent molecular type but VNII, VNIV and VNIII hybrid strains were also isolated. With the exception of a single VGIV isolate, all C. gattii isolates were VGI. The results confirmed the presence of both Cryptococcus species in the Mediterranean environment, and showed that both carob and olive trees represent an important niche for these yeasts. United States Department of Health & Human Services National Institutes of Health (NIH) - USA - ZIAAI000744 NIH National Institute of Allergy & Infectious Diseases (NIAID) CITAB - UID/AGR/04033/2013 National Health and Medical Research Council (NHMRC) of Australia - APP1031943 Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (CAPES) - 9313133

Rhodotorula species including Rhodotorula minuta are emerging yeast pathogens defined particularly in immunocompromised patients. In this study the patient was a woman with a history of diabetes mellitus (DM) and uterus cancer, which was treated with chemotherapy following hysterectomy. The patient had more than one operation on her hip joint due to several complaints including restriction in movement and severe pain. The cultures obtained during operations revealed several microorganisms including Candida albicans, Enterobacter cloacae, ESBL (+) Escherichia coli and lastly R. minuta. The last agent, R. minuta was treated successfully with fluconazole. This is the second case of hip joint infection caused by R. minuta, which was hardly isolated following a long period of cultivation.

Pichia anomala is an emerging yeast causing serious nosocomial infections in newborn and immunocompromised children. We describe nosocomial port catheter infection due to P. anomala in three children who were receiving cancer chemotherapy, bloodstream infection in a preterm infant and in an infant with severe combined immunodeficiency. All patients were treated with amphotericin B. All isolates were susceptible to amphotericin B and fluconazole. No recurrence was observed during follow-up in four of five patients. The common clinical feature in all of our patients was the presence of prior antimicrobial therapy.

Candida colliculosa , which grew in blood cultures of a 71-year-old retired man with fever of unknown origin that had lasted for 7 months, in conjunction with transthoracic echocardiography, demonstrating a 20-mm vegetation, superior to the tricuspid valve, herniating into the right atrial cavity. The finding led to the diagnosis of fungal endocarditis. Fluconazole, 600 mg daily, was commenced for 8 days; followed by amphotericin B, 1 mg/kg daily. On the fourth day of the amphotericin B treatment, the patient underwent replacement of the infected tricuspid valve. Even though the initial postoperative period was relatively uncomplicated, the patient died after a gross aspiration on the 67th day of his hospital stay, despite aggressive cardiovascular support and antimicrobial therapy. This is the first report of a native tricuspid valve fungal endocarditis due to C. colliculosa or Torulaspora delbrueckii , which is not known to be a human pathogen.

In this study, we aimed to detect the proportion of Candida dubliniensis among yeast strains previously identified as C. albicans by using several phenotypic methods and PCR.For this purpose, we screened 300 strains by using phenotypic tests suggested for the identification of C. dubliniensis in the literature, but we detected high proportion of false-positive reactions. Only two strains (0.6%) were detected as true C. dubliniensis by PCR and API ID 32C methods. Moreover, these two strains gave the expected results with all the phenotypic tests, including modified salt tolerance test for C. dubliniensis.In conclusion, none of the phenotypic methods, except for the modified salt tolerance test, revealed 100% successful results in discrimination of C. albicans and C. dubliniensis species. However, in the tobacco agar test, the rate of false positivity was as low as 0.6%. We suggest that in the case of absence of PCR and other automatized identification systems, these two phenotypic tests can be used in routine laboratories to obtain a presumptive result.

Three virulence factors comprising proteinase, phospholipase, and biofilm among 68 Candida albicans and 31 non-albicans Candida strains (11 C. tropicalis, 8 C. parapsilosis, 6 C. glabrata, 4 C. guillermondii, 2 C. krusei) isolated from blood cultures were analyzed. In total, 61 (89.7%) C. albicans strains were detected as proteinase positive whereas eight (25.8%) non-albicans Candida strains were proteinase positive (P < 0.05). Phospholipase production was detected in 41 (60.3%) C. albicans strains. All non-albicans Candida strains were phospholipase negative. Biofilm production was determined by both visual and spectrophotometric methods. Eight (11.8%) of C. albicans strains and 13 (41.93%) of 31 non-albicans Candida strains were biofilm positive with two of the methods (P < 0.05). According to our results, we may suggest that detection of hydrolytic enzyme and biofilm production abilities of the Candida isolates in clinical mycology laboratories may warn the clinican for a possible hematogenous infection.

In order to determine the local epidemiology of candidemia, Candida strains isolated between 1994 and 2000 were identified to species level; antifungal resistance patterns and DNA fingerprints were analyzed. Identification of Candida strains (n: 140) was performed with germ tube test and carbohydrate assimilation reactions. Minimal inhibitory concentrations were determined using a commercial test for 5-flucytosine and the broth macrodilution method according to NCCLS for fluconazole and amphotericin B. Molecular relatedness was determined by restriction endonuclease analysis of genomic DNA followed by probe hybridization. C. albicans (37.2%), C. parapsilosis (32.2%), and C. tropicalis (12.2%) comprised 114 (81.4%) of 140 isolates. Susceptibility tests did not reveal resistance to amphotericin B in any of the Candida isolates. Fluconazole resistance was detected in one isolate of C. krusei, and 5-flucytosine resistance in two C. tropicalis isolates and one C. albicans isolate. Significantly higher frequency of clusters with identical strains in C. parapsilosis and C. tropicalis was detected compared to C. albicans. Pediatric wards are particularly important in the nosocomial transmission of non-albicans candida species.

In this study, we investigated the presence of virulence factors in a total of 33 Candida parapsilosis strains, including adherence, acid proteinase and phospholipase production capabilities. Of the 33 strains, 19 were isolated from blood cultures of hospitalised fungaemic patients (study group 2). We also investigated the importance of other factors present in the development of fungaemia. The mean adherence values of 19 blood isolates and 14 non-blood isolates were found to be 52.63 and 57.96, respectively; these values did not differ significantly (P > 0.05). Nine non-blood strains (64.29%) of study group 2 and five blood strains (26.31%) of study group 1 were found to be positive for acid proteinase production; this difference was statistically significant (P < 0.05). Phospholipase production was found in five strains (26.31%) of the 19 blood isolates. None of the 14 non-blood strains exhibited phospholipase activity; this difference between the two groups was statistically significant (P < 0.05). In this study, correlations between adherence-phospholipase, and adherence-acid proteinase properties of strains were detected as well. In the present study, it has been observed that phospholipase production can be an important virulence factor in bloodstream infections caused by C. parapsilosis.

Early detection of slime production may be useful for clinical decision because of its suggestive property for potential pathogenic capacity of a Candida strain especially in patients with a prosthetic device. In this study we aimed to compare the visual tube method (VTM) with transmission electron microscopy (TEM) in order to confirm the reliability of the former method. In order to demonstrate the reproducibility of the tube method and to determine the correct timing for the test, Candida isolates directly obtained from blood culture (DBC) bottles and their two subsequent subcultures were used. The results of this study showed that VTM is a simple and reliable method which can be used in every clinical mycology laboratory, provided that the test is applied on DBC isolates; as the ability of slime production is decreased or lost even after the first subculturing. We suggest that this simple method can be used and may have some contributions to the ongoing studies on the controversial issue concerning removal of biomaterials in candidemic patients.

OBJECTIVES: In this study, 210 women with vaginal discharge and other symptoms/signs of genital pathology suggestive of vulvovaginal candidiasis (VVC) were involved in order to distinguish true WC and cytolytic vaginosis (CV) cases. METHODS: Fungal cultures, 10% potassium hydroxide (KOH) and Gram stained preparations and pH measurements were performed on the vaginal discharge material of each patient. RESULTS: Fifteen patients (7.1%) were diagnosed with cytolytic vaginosis according to their clinical and microbiological findings, including abundant lactobacilli, fragmented epithelial cells and/or free nuclei due to cytolysis, seen in their discharge materials on microscopic examination, but no fungal growth. CONCLUSIONS: The results of this study may contribute to the reports in the literature indicating the importance of such disorders, which are generally misdiagnosed as candidiasis.

A 24-year-old male patient with acute myeloid leukemia (AML), who had been in remission for 18 months following the completion of chemotherapy, presented with fatigue and nasal bleeding. He was found to have pancytopenia, and bone marrow aspiration showed relapsed AML. He was given high-dose sequential chemotherapy consisting of cytosine arabinoside, 500 mg/m per day as a 24-h continuous infusion, idarubicin, 12 mg/m per day on days 1–3, etoposide, 200 mg/m per day as a 24-h continuous infusion on days 8–10, and granulocyte colony-stimulating factor (GCSF), 5 mg/kg per day subcutaneously, starting from day 12 until absolute neutrophil recovery above 1000/mL. The patient became neutropenic, with a count below 100/mL, on the 5th day of chemotherapy. He was pyrexial on the next day, with a temperature of 39 8C, without any localizing symptoms or signs of infection. Blood cultures were taken, and chest X-ray was normal. Empirical antibiotic therapy with piperacillin–tazobactam was commenced, and vancomycin was added 48 h later, when no response was obtained. Examination revealed widespread oral mucositis on the fourth day of the febrile neutropenic episode. Blood cultures, which had been taken every other febrile day, revealed extended-spectrum b-lactamase-producing Escherichia coli on the seventh day of pyrexia, and meropenem and amikacin were substituted for piperacillin–tazobactam. Total parenteral nutrition was also commenced on the same date, as the patient now suffered from severe dysphagia and could not tolerate any oral intake. Fever and dysphagia continued, and an endoscopy was performed, revealing esophageal candidiasis on the 12th day of pyrexia. Fluconazole, 6 mg/kg per day, was commenced intravenously. A non-albicans Candida sp. was grown in both esophageal and blood cultures on the 14th day of pyrexia, and fluconazole was changed to amphotericin B deoxycholate, 0.7 mg/kg per day, due to continuing pyrexia and the possibility of a fluconazole-resistant Candida sp. Surprisingly, two different non-albicans Candida species were identified later, with esophageal cultures revealing C. krusei, whereas blood cultures yielded C. kefyr with a fluconazole MIC of 4 mg/L and an amphotericin B deoxycholate MIC of 0.25 mg/L. Fundoscopic examination was negative for candida retinitis. The patient’s neutrophil count rose above 500/ mL on the 19th day of pyrexia (25th day following chemotherapy). Mucositis and dysphagia gradually resolved with a subsequent increase in the oral intake, and parenteral nutrition was terminated. However, pyrexia reaching 39 8C continued. Amphotericin B deoxycholate was replaced with liposomal amphotericin B, 100 mg, daily due to hypokalemia refractory to intravenous replacement therapy, and meropenem, amikacin and vancomycin treatment was terminated on the 26th day of pyrexia. The patient remained febrile, and liver transaminase levels were found to be elevated. Abdominal CT on the 33rd day of pyrexia demonstrated numerous, prominent hypodense lesions within the spleen, and few lesions in the liver and kidneys, consistent with abscesses. A diagnosis of chronic disseminated candidiasis (CDC) was made. A bone marrow aspirate at this stage confirmed that the patient’s AML was still