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COVID-19-associated pulmonary aspergillosis (CAPA) has been widely reported but homogenous large cohort studies are needed to gain real-world insights about the disease.We collected clinical and laboratory data of 1161 patients hospitalised at our Institute from March 2020 to August 2021, defined their CAPA pathology, and analysed the data of CAPA/non-CAPA and deceased/survived CAPA patients using univariable and multivariable models.The overall prevalence and mortality of CAPA in our homogenous cohort of 1161 patients were 6.4% and 47.3%, respectively. The mortality of CAPA was higher than that of non-CAPA patients (hazard ratio: 1.8 [95% confidence interval: 1.1-2.8]). Diabetes (odds ratio [OR] 1.92 [1.15-3.21]); persistent fever (2.54 [1.17-5.53]); hemoptysis (7.91 [4.45-14.06]); and lung lesions of cavitation (8.78 [2.27-34.03]), consolidation (9.06 [2.03-40.39]), and nodules (8.26 [2.39-28.58]) were associated with development of CAPA by multivariable analysis. Acute respiratory distress syndrome (ARDS) (2.68 [1.09-6.55]), a high computed tomography score index (OR 1.18 [1.08-1.29]; p .001), and pulse glucocorticoid treatment (HR 4.0 [1.3-9.2]) were associated with mortality of the disease. Whereas neutrophilic leukocytosis (development: 1.09 [1.03-1.15] and mortality: 1.17 [1.08-1.28]) and lymphopenia (development: 0.68 [0.51-0.91] and mortality: 0.40 [0.20-0.83]) were associated with the development as well as mortality of CAPA.We observed a low but likely underestimated prevalence of CAPA in our study. CAPA is a disease with high mortality and diabetes is a significant factor for its development while ARDS and pulse glucocorticoid treatment are significant factors for its mortality. Cellular immune dysregulation may have a central role in CAPA from its development to mortality.

Pulmonary mucormycosis is rare in systemic lupus erythematosus. A 20-year-old lady with lupus nephritis and neuropsychiatric lupus was treated with injection methylprednisolone and cyclophosphamide. After few days, she developed fever, breathlessness, and hoarseness of voice. After neck and chest imaging, possibility of mucormycosis was considered which was later confirmed on microbiological test. Patient was treated with conventional amphotericin B. Literature review was done, and 8 patients with disseminated or pulmonary mucormycosis were identified with SLE. In patients with high index of suspicion, early imaging can help in diagnosis and early and aggressive management even with conventional amphotericin B can result in favorable outcome. Key Points • Pulmonary mucormycosis in systemic lupus erythematosus is rare. • Radiological investigation can guide towards diagnosis. • Early and aggressive treatment can lead to good outcome.

During September-December 2020, we conducted a multicenter retrospective study across India to evaluate epidemiology and outcomes among cases of coronavirus disease (COVID-19)-associated mucormycosis (CAM). Among 287 mucormycosis patients, 187 (65.2%) had CAM; CAM prevalence was 0.27% among hospitalized COVID-19 patients. We noted a 2.1-fold rise in mucormycosis during the study period compared with September-December 2019. Uncontrolled diabetes mellitus was the most common underlying disease among CAM and non-CAM patients. COVID-19 was the only underlying disease in 32.6% of CAM patients. COVID-19-related hypoxemia and improper glucocorticoid use independently were associated with CAM. The mucormycosis case-fatality rate at 12 weeks was 45.7% but was similar for CAM and non-CAM patients. Age, rhino-orbital-cerebral involvement, and intensive care unit admission were associated with increased mortality rates; sequential antifungal drug treatment improved mucormycosis survival. The COVID-19 pandemic has led to increases in mucormycosis in India, partly from inappropriate glucocorticoid use.

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Introduction Candida spp. accounts for 70%-80% of invasive bloodstream fungal infections. It is most commonly spread in long-term care facilities, caring for people with severe medical conditions. Patients hospitalized for COVID-19 are at risk for healthcare-associated infections like candidemia. Candida auris is an emerging, multidrug-resistant, healthcare-associated fungal pathogen. Candida auris is currently one of the most common clinical fungal pathogens, causing nosocomial infections. Due to its higher drug-resistance rate, C. auris is more difficult to treat, requires longer hospitalization periods, and results in higher morbidity and mortality than other Candida species. Aim and Objectives To analyze the risk factors associated with C. auris candidemia in COVID-19 and post-COVID-19 patients at tertiary care center. Material and Methods We prospectively analyzed all positive blood samples which were received in the Microbiology department at SGPGI, Lucknow for a period of 1 year (March 2020-March 2021). Blood samples were inoculated and cultured in BACTEC Bottles (BD) and incubated for 5 days at 37°C. The bottles which flagged positive, a Gram's stain was performed and were sub-cultured on SDA for isolation of yeast colonies. Isolated yeasts were identified by phenotypic method and confirmed by MALDI-TOF MS. Demographics details of the patients were collected and recorded. The significant associated risk factors with C. auris candidemia were analyzed. Results A total of 13 000 blood samples were received during the 1-year study period from different departments of the hospital.1.25% (n = 163) of the blood culture samples were positive for candidemia. Out of 163 Candida culture-positive blood samples, 27.61% (n = 45) were C. auris. A total of 64% (n = 29) C. auris candidemia was seen in non-COVID-19 patients, 31.1% (n = 14) in COVID-19 patients, and two patients had a history of post-COVID-19 infection. The associated risk factors included the use of broad-spectrum antibiotics, intravenous catheterization, underlying respiratory illness, mechanical ventilation, use of steroids, and dialysis. A total of 46.6% (n = 21) mortality was seen with C. auris candidemia. Conclusions Candida auris candidemia continues to be a threat in hospitalized patients. This study shows prevalence of C. auris candidemia in COVID-19 and post-COVID-19 patients with 47% mortality. Candida auris is continuously reported from different departments in our institute, especially from intensive care units with high morbidity and mortality. An alertness, awareness and infection control practices by the healthcare personnel will help in early diagnosis and appropriate antifungal therapy and control the spread of C. auris.

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives The study was aimed to determine the patient demographics, risk factors, which include comorbidities, presenting symptoms and signs, medications used to treat COVID-19, species of Mucorales isolated, and the management outcome of COVID-19-associated mucormycosis. Methods It was a 6-month retrospective, propensity score-matched, comparative study conducted at a tertiary care center, involving 124 patients with COVID-19 associated mucormycosis admitted between April and September 2021, who were suffering from or had a history of COVID-19 infection. Results Among the 124 patients, 87 were male, and 37 were female. A total of 72.6% of patients received steroids, while 73.4% received antibiotics, and 55.6% received oxygen during COVID-19 management. The most common comorbidities were diabetes mellitus (83.9%) and hypertension (30.6%). A total of 92.2% had mucor, 16.9% had Aspergillus, 12.9% had both, and one patient had hyalohyphomycosis on fungal smear and culture. The comparative study showed the significant role of serum ferritin, glycemic control, steroid use, and duration in COVID-19-associated invasive fungal disease (P Conclusion COVID-19-related aggressive inflammatory response, uncontrolled glycemic level, and rampant use of steroids are the most important predisposing factors in developing COVID-19-associated invasive fungal sinusitis caused by Mucorales. A high index of suspicion, aggressive surgical and antifungal therapy resulted in the successful outcomes for most of the patients.

Objective The aim of this study was to identify and isolate Trichosporon asahii (T. asahii) from clinical samples and to assess the genetic relatedness of the most frequently isolated strains of T. asahii using random amplification of polymorphic DNA (RAPD) primers GAC-1 and M13. Methods All the clinical samples that grew Trichosporon species, identified and confirmed by polymerase chain reaction (PCR) using Trichosporon genus-specific primers, were considered for the study. Confirmation of the species T. asahii was carried out by T. asahii-specific PCR. Fingerprinting of the most frequently isolated T. asahii isolates was carried out by RAPD using random primers GAC-1 and M13. Results Among the 72 clinical isolates of Trichosporon sp. confirmed by Trichosporon-specific PCR, 65 were found to be T. asahii as identified by T. asahii-specific PCR. Fingerprinting of the 65 isolates confirmed as T. asahii using GAC-1 RAPD primer yielded 11 different patterns, whereas that of M13 primer produced only 5 patterns. The pattern I was found to be the most predominant type (29.2%) followed by pattern III (16.9%) by GAC-1 primer. Conclusions This study being the first of its kind in India on strain typing of T. asahii isolates by adopting RAPD analysis throws light on genetic diversity among the T. asahii isolates from clinical samples. Fingerprinting by RAPD primer GAC-1 identified more heterogeneity among the T. asahii isolates than M13.

Background: Histoplasmosis is an endemic mycosis caused by Histoplasma Capsulatum, a thermally dimorphic fungus with mycelial and yeast forms. Muscle involvement is infrequent in Histoplasmosis. Case: A 49-year-old lady presented with generalized myalgia and arthritis of two-year duration, which had responded partly to glucocorticoids. The lady reported to us two years into the illness with ulcerative eyelid lesions, worsening myalgia, and painful skin nodules. Eventually, it turned out that anti-synthetase syndrome was the primary diagnosis with Histoplasma infection in the muscles, subcutaneous tissue, and eye. We herewith present the course of her illness and a review of Histoplasmosis of the muscle in literature. Conclusion: The differential diagnosis of painful muscle weakness is broad. Histoplasma capsulatum infection should be considered in immunosuppressed myositis patient presenting with orbital ulcers, skin nodules and worsening muscle weakness.

Coronavirus disease-2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a new disease characterized by secondary Aspergillus mold infection in patients with COVID-19. It primarily affects patients with COVID-19 in critical state with acute respiratory distress syndrome, requiring intensive care and mechanical ventilation. CAPA has a higher mortality rate than COVID-19, posing a serious threat to affected individuals. COVID-19 is a potential risk factor for CAPA and has already claimed a massive death toll worldwide since its outbreak in December 2019. Its second wave is currently progressing towards a peak, while the third wave of this devastating pandemic is expected to follow. Therefore, an early and accurate diagnosis of CAPA is of utmost importance for effective clinical management of this highly fatal disease. However, there are no uniform criteria for diagnosing CAPA in an intensive care setting. Therefore, based on a review of existing information and our own experience, we have proposed new criteria in the form of practice guidelines for diagnosing CAPA, focusing on the points relevant for intensivists and pulmonary and critical care physicians. The main highlights of these guidelines include the role of CAPA-appropriate test specimens, clinical risk factors, computed tomography of the thorax, and non-culture-based indirect and direct mycological evidence for diagnosing CAPA in the intensive care unit. These guidelines classify the diagnosis of CAPA into suspected, possible, and probable categories to facilitate clinical decision-making. We hope that these practice guidelines will adequately address the diagnostic challenges of CAPA, providing an easy-to-use and practical algorithm to clinicians for rapid diagnosis and clinical management of the disease.

Objective Detailed studies of Addison's disease resulting from disseminated adrenal histoplasmosis (AH) are not available. We describe the presentation and prognosis of AH and cortisol status before and after antifungal therapy. Design Single-centre retrospective hospital-based study of 40 consecutive adults with AH [39 males; age (mean ± SD) 53 ± 11 years] was conducted between 2006 and 2018. The median duration of follow-up was 2.5 years (range 0.2-12 years). Patients and methods AH was diagnosed by bilateral adrenal enlargement on CT scan and presence of Histoplasma by histology and/or culture of biopsied adrenal tissue. All patients received oral itraconazole and, if required, amphotericin B as per guidelines. ACTH-stimulated serum cortisol (normal > 500 nmol/L) was measured in 38 patients at diagnosis and re-tested after one year of antifungal therapy in 21 patients. Results Seventy-three per cent of patients had primary adrenal insufficiency (PAI) and one-third had an adrenal crisis at presentation. HIV antibody was negative in all patients. Of the 29 patients who completed antifungal therapy, 25 (86%) were in remission at last follow-up. Overall, 8 (20%) patients died: three had a sudden death, four had severe histoplasmosis and one died due to adrenal crisis. No patient with PAI became eucortisolemic on re-testing after one year of antifungal therapy. Of the eight patients with normal cortisol at diagnosis, two developed adrenal insufficiency on follow-up. Conclusion All patients with AH tested negative for HIV antibody. While patients achieved a high rate of clinical remission after antifungal therapy, overall mortality was significant. Cortisol insufficiency did not normalize despite treatment.

Objective: Invasive candidiasis is associated with increased morbidity and mortality in critically ill patients. Current study was undertaken to study the colonization trend in critically ill patients admitted to a medical /surgical ICU of a tertiary care teaching hospital. Methodology: Data for the current study has been derived from a larger database generated for external validation of risk prediction scores for invasive candidiasis conducted in a 12 bedded medical/surgical ICU of a tertiary care hospital of North India. Non neutropenic adult patients with >48 hours of ICU stay were included in the study. Colonization surveillance samples were collected from oral cavity, endotracheal aspirates, axilla, perineum and urine at the time of admission and then on 3rd, 7th, 14th and 21st day of ICU stay. Blood culture samples were taken at admission and then as per physician’s discretion. Results: Total 200 patients were enrolled from July 2013 to November 2014. Ninety five percent patients were colonized with Candida either at admission or during their stay in ICU. The most common species responsible for colonization was Candida glabrata (27%) followed by C. tropicalis (20.5%) and C. auris (18%). Seventeen patients developed Candida blood stream infection. C. tropicalis was the most common species causing candidemia. C.auris was most frequent colonizer of axilla (54.2%), while rectal swabs had high growth of C. glabrata (44.9%). Conclusion: Our study population had high rate of Candida colonization. C. glabrata was the most common colonizer followed by C. tropicalis. J Microbiol Infect Dis 2018; 8(4):147-152.

Background Isolated renal mucormycosis (IRM) is a potentially fatal disease affecting immunocompromised hosts. IRM affecting apparently immunocompetent patients is rare, with few previous reports, mostly from India. We describe 10 cases of bilateral IRM with no underlying risk factors. Methods We performed a retrospective analysis of cases of IRM from our hospital information system admitted between 2009 and 2016. We analyzed the data of this cohort of IRM, including epidemiological characteristics, clinical presentation, diagnostic procedures, treatment details and outcome. Results In all, 10 cases of bilateral IRM were identified. All of them were males with a mean age of 24.7 years (range 10–42). Most patients were initially managed as acute bacterial pyelonephritis with acute kidney injury. A total of eight patients were diagnosed antemortem. Diagnostic clues include sepsis not controlled with broad-spectrum antibiotics and enlarged kidneys with or without hypodensities on ultrasound/computed tomography imaging. Three patients also gave a specific history of passing white flakes in their urine. Eight patients received specific antifungal therapy with amphotericin B with or without posaconazole. Three patients in whom the disease was apparently confined to the pelvicalyceal system underwent local irrigation with Amp-B. One patient underwent bilateral nephrectomy. Four patients succumbed to the disease while five patients were successfully treated. One patient was discharged against medical advice. Conclusions IRM is a rare, life-threatening disease associated with high mortality even in immunocompetent individuals. Typical clinical and radiological findings and a high index of suspicion may help in early diagnosis, but definitive diagnosis requires histopathological and/or microbiological confirmation. Early and rapid diagnosis along with aggressive multidisciplinary management including initiation of specific antifungal therapy with or without surgical debridement is vital for a successful outcome.

Background and aims Risk of infections is increased in patients with Acute Liver Failure (ALF) and Decompensated Chronic Liver Disease (DCLD). We evaluated the frequency, site, type and risk-factors for bacterial infections in children with ALF and DCLD and its effect on outcome. Methods ALF or DCLD children were enrolled prospectively. Clinical and laboratory details were recorded. Cultures (blood, urine and ascites) and chest X-ray were done at admission followed by weekly surveillance cultures. Results 173 patients, 68 ALF and 105 DCLD were enrolled. Infections were more common in DCLD than ALF (60/105 [57.1%] vs. 27/68 [39.7%]; P = 0.02). Ascitic fluid infection, pneumonia, urinary tract infection and bacteremia were seen in 19%, 17.9%, 13.2% and 12.1% patients respectively. Healthcare-Associated (HCA) infections were most frequent (39/87, 44.8%), followed by Nosocomial (NC, 32%) and Community-Acquired (CA, 23%). Nearly 3/4th of bacterial isolates were resistant to cephalosporins and quinolones, 23% being Multiresistant Bacteria (MRB). DCLD patients with infection had higher Child–Pugh Score (10 [6–14] vs. 7 [6–14]; OR 3.2 [1.77–5.10]: P = 0.007), need for ICU care (26/60 vs. 3/45; OR 10.70 [2.98–38.42]: P = 0.01), in-hospital mortality (24/60 vs. 8/45;OR 3.08 [1.22–7.75]: P = 0.04) and mortality at 3 month follow-up (32/60 vs. 9/45; OR 4.57 [1.87–11.12]: P = 0.00). Infection did not affect the outcome in ALF. Conclusion Infections develop in 40% ALF and 57% DCLD children. HCA and NC infections account for 77% of infections. Most culture isolates are resistant to cephalosporins and fluoroquinolones and 23% have MRB. Risk of infections is higher in DCLD patients with advanced liver disease.

Objectives To identify the risk factors associated with Candida auris candidaemia, as this fungus now poses a global threat. Methods We performed a subgroup analysis of a previously reported study of 27 Indian ICUs. The clinical data of candidaemia cases due to C. auris and other Candida species were compared to determine significant risk factors associated with C. auris infection. Results Of the 1400 candidaemia cases reported earlier, 74 (5.3%) from 19 of 27 ICUs were due to C. auris . The duration of ICU stay prior to candidaemia diagnosis was significantly longer in patients with C. auris candidaemia (median 25, IQR 12-45 days) compared with the non- auris group (median 15, IQR 9-28, P < 0.001). Based on logistic regression modelling, admission to north Indian ICUs [OR 2.1 (1.2-3.8); P = 0.012], public-sector hospital [OR 2.2 (1.2-3.9); P = 0.006], underlying respiratory illness [OR 2.1 (1.3-3.6); P = 0.002], vascular surgery [OR 2.3 (1.00-5.36); P = 0.048], prior antifungal exposure [OR 2.8 (1.6-4.8); P < 0.001] and low APACHE II score [OR 0.8 (0.8-0.9); P = 0.007] were significantly associated with C. auris candidaemia. The majority (45/51, 88.2%) of the isolates were clonal. A considerable number of isolates were resistant to fluconazole ( n = 43, 58.1%), amphotericin B ( n = 10, 13.5%) and caspofungin ( n = 7, 9.5%). Conclusions Although C. auris infection has been observed across India, the number of cases is higher in public-sector hospitals in the north of the country. Longer stay in ICU, underlying respiratory illness, vascular surgery, medical intervention and antifungal exposure are the major risk factors for acquiring C. auris infection even among patients showing lower levels of morbidity.

Background The aim of this study was to conduct external validation of risk prediction scores for invasive candidiasis. Methods We conducted a prospective observational study in a 12-bedded adult medical/surgical Intensive Care Unit (ICU) to evaluate Candida score >3, colonization index (CI) >0.5, corrected CI >0.4 (CCI), and Ostrosky's clinical prediction rule (CPR). Patients' characteristics and risk factors for invasive candidiasis were noted. Patients were divided into two groups; invasive candidiasis and no-invasive candidiasis. Results Of 198 patients, 17 developed invasive candidiasis. Discriminatory power (area under receiver operator curve [AUROC]) for Candida score, CI, CCI, and CPR were 0.66, 0.67, 0.63, and 0.62, respectively. A large number of patients in the no-invasive candidiasis group (114 out of 181) were exposed to antifungal agents during their stay in ICU. Subgroup analysis was carried out after excluding such patients from no-invasive candidiasis group. AUROC of Candida score, CI, CCI, and CPR were 0.7, 0.7, 0.65, and 0.72, respectively, and positive predictive values (PPVs) were in the range of 25%-47%, along with negative predictive values (NPVs) in the range of 84%-96% in the subgroup analysis. Conclusion Currently available risk prediction scores have good NPV but poor PPV. They are useful for selecting patients who are not likely to benefit from antifungal therapy.

Polymyositis is a diagnosis of exclusion. In patients with odd features, it can be of infective etiology. A high index of suspicion is required for diagnosis. A 55-year-old gentleman presented with gradual-onset proximal muscle weakness. Examination revealed mild distal weakness but no rash. Muscle enzymes were raised and tests for autoantibodies were negative. Biopsy revealed microsporidiosis. In view of this unusual infection, immunodeficiency was considered and he was found to have lymphopenia which antedated his illness. Later, he developed cranial nerve palsies due to multiple lesions in the pons. In addition, he had Cytomegalovirus viremia. Literature was reviewed to identify 20 cases of microsporidial myositis, its presentation, underlying immunodeficient state, and clinical course. Infective polymyositis should be considered in a patient with paucity of clinical and serological autoimmune features. Lymphopenia can point to underlying immunodeficiency. CMV infection could be the contributor to or bystander-effect of idiopathic lymphopenia.

Central nervous system nocardiosis is a rare, life-threatening infection seen commonly in immunocompromised individuals. Nocardia neocaledoniensis is a novel species seldom causing infections in humans. We describe a patient of sarcoidosis on immunosuppression, who presented with altered sensorium due to a frontal lobe abscess secondary to N. neocaledoniensis infection. Despite appropriate and adequate antibiotic coverage, and timely surgical intervention, the patient succumbed to her illness on day 6 of hospitalisation. This case warrants the consideration of novel infections in patients on immunosuppression and the need for aggressive management.

Objectives To study outcomes with voriconazole therapy in immunocompetent individuals following maximal safe endoscopic resection in invasive aspergillosis of the anterior skull base. Design Retrospective study of patients with chronic invasive aspergillosis including symptomatology, extent of disease, and response to voriconazole following maximal safe resection in immunocompetent individuals. Setting Tertiary care superspeciality referral center. Participants Ten consecutive patients of invasive aspergillosis of anterior skull base managed over a period of 2 years. Main Outcome Measures Symptom resolution with systemic voriconazole and radiologic evaluation following systemic antifungals as per predefined protocol. Conclusions Maximal safe resection via transnasal endoscopic route followed by systemic antifungals provides excellent outcomes in invasive skull base aspergillosis. Although liver and renal functions, besides visual acuity, need serial monitoring, voriconazole is well tolerated by our patients.

Objective: Adrenal enlargement occurs in various conditions such as infections, benign, and malignant neoplasms. Percutaneous computed tomography (CT)-guided adrenal biopsy is a safe method for obtaining tissue specimen in cases where diagnosis cannot be established on imaging and biochemical grounds. The study aims to evaluate diagnostic yield, accuracy, and complications of percutaneous CT-guided adrenal biopsies. Furthermore, CT findings of various adrenal lesions have been described. Materials and Methods: Data of CT-guided adrenal biopsies performed from September 2009 to May 2019 were analyzed. Biopsies were performed on a 64-slice or a 128-slice multidetector CT scanner using a coaxial technique. Pathological and microbiological reports were retrieved from the hospital information system. Clinical details were obtained from clinical case records. Results: CT-guided adrenal biopsies were performed in 48 patients, 37 males and 11 females. Adrenal insufficiency was present in 31 (64%) cases and bilateral adrenal glands were affected in 35 (73%). Biopsy yielded a diagnosis in 35 cases (72.9%). The final diagnosis was achieved in 43 (90%) cases. Combined accuracy of CT-guided biopsy for identifying malignancy and infection was 88.3%. Adrenal histoplasmosis (AH) was the most common entity diagnosed (44%). After combining histopathology and microbiology results, the sensitivity for diagnosing AH was 100%. One (2%) patient had a major complication in the form of intra-abdominal hemorrhage requiring transfusion. Local hematoma and mild stable pneumothorax were noted in one patient each. Conclusion: Percutaneous CT-guided biopsy is a safe procedure for the diagnosis of adrenal lesions. It has good accuracy for diagnosing adrenal conditions such as infections and malignancies. However, the specific diagnosis of benign adrenal lesions was difficult to make. AH, tuberculosis, and metastasis have overlapping imaging findings.

We present a case of brain abscess in an immunocompetent child due to the dematiaceous fungus Microascus cinereus, an organism commonly found in soil and stored grains. The etiologic agent was demonstrated by direct microscopy and culture. The patient responded well to surgical excision of abscess along with a course of amphotericin B and voriconazole. Microascus species have emerged as significant invasive pathogens especially in the immunocompromised patients. To the best of our knowledge, this is the first reported case of brain abscess caused by M. cinereus in an immunocompetent individual with no underlying risk factors.

History A 21-year-old man presented with swelling of the medial aspect of the left thigh of 1-month duration. There was no history of fever or penetrating injury in the left thigh. The patient had undergone renal transplantation 7 years earlier and had been taking immunosuppressants since transplantation. He had undergone two surgeries at the same site in the medial aspect of the left thigh in the past 3 years for a similar problem. At physical examination, there was swelling in the medial aspect of the left thigh, with mild tenderness. A surgical scar was noted anterior to the swelling ( Fig 1 ). No redness or discharging sinus was present. Laboratory results were as follows: hemoglobin level, 11.3 g/dL (normal range, 13.8-17.2 g/dL); white blood cell count, 9.7 × 10

The epidemiology of candidaemia varies between hospitals and geographic regions. Although there are many studies from Asia, a large-scale cross-sectional study across Asia has not been performed. We conducted a 12-month, laboratory-based surveillance of candidaemia at 25 hospitals from China, Hong Kong, India, Singapore, Taiwan and Thailand. The incidence and species distribution of candidaemia were determined. There were 1601 episodes of candidaemia among 1.2 million discharges. The overall incidence was 1.22 episodes per 1000 discharges and varied among the hospitals (range 0.16–4.53 per 1000 discharges) and countries (range 0.25–2.93 per 1000 discharges). The number of Candida blood isolates and the total number of fungal isolates were highly correlated among the six countries ( R ² = 0.87) and 25 hospitals ( R ² = 0.77). There was a moderate correlation between incidence of candidaemia and the intensive care unit (ICU)/total bed ratio ( R ² = 0.47), although ICUs contributed to only 23% of candidaemia cases. Of 1910 blood isolates evaluated, Candida albican s was most frequently isolated (41.3%), followed by Candida tropicalis (25.4%), Candida glabrata (13.9%) and Candida parapsilosis (12.1%). The proportion of C. tropicalis among blood isolates was higher in haemato-oncology wards than others wards (33.7% versus 24.5%, p 0.0058) and was more likely to be isolated from tropical countries than other Asian countries (46.2% versus 18.9%, p 0.04). In conclusion, the ICU settings contribute, at least in part, to the incidence variation among hospitals. The species distribution is different from Western countries. Both geographic and healthcare factors contribute to the variation of species distribution.

Use of antifungal agents has increased over past few decades. A number of risk factors such as immunosuppression, broad spectrum antibiotics, dialysis, pancreatitis, surgery, etc., have been linked with the increased risk of invasive candidiasis. Though there are various guidelines available for the use of antifungal therapy, local/regional epidemiology plays an important role in determining the appropriate choice of agent in situations where the offending organism is not known (i.e. empirical, prophylactic or preemptive therapy). Developing countries like India need to generate their own epidemiological data to facilitate appropriate use of antifungal therapy. In this article, the authors have highlighted the need for region-specific policies/guidelines for treatment of invasive candidiasis. Currently available Indian literature on candidemia epidemiology has also been summarized here.

Background: Invasive candidiasis (IC) is associated with increased morbidity in severe acute pancreatitis (SAP). There is limited information regarding the predisposing factors, Candida species distribution and in vitro susceptibility. Methodology: Current data have been derived from a larger prospective nonintervention study conducted on 200 critically ill patients which was done to study the antifungal prescription practices, collect epidemiological data, and perform an external validation of risk prediction models for IC under senior research associateship program of Council of Scientific and Industrial Research New Delhi. Of these critically ill patients, thirty had SAP and were included for analysis. Results: There were 23 males and 7 females. Out of eight patients (27%) who developed IC, three had isolated candidemia, two had isolated deep-seated candidiasis while three had both candidemia and deep-seated candidiasis. SAP patients with IC had a longer duration of Intensive Care Unit stay, hospital stay, days on mechanical ventilation and duration of shock. Mortality was not different between SAP patients with or without IC. Conclusion: There is a high rate of Candida infection in SAP. More studies are needed to generate epidemiological data and develop antifungal stewardship in this subset of high-risk population.

Early and accurate identification of infection in patients with liver disease is challenging. The present study evaluated the role of procalcitonin (PCT) and C-reactive protein (CRP) as biomarkers of bacterial infection in children with liver disease.Demographic and clinical data of consecutive children admitted with acute liver failure (ALF) or decompensated chronic liver disease (DCLD) were collected. PCT and CRP were measured within 24 hours of admission. Blood and urine culture, chest x-ray, and ascitic fluid analysis were done.One hundred sixty-four children (113 boys, age 76 [0.5-204] months, ALF 69, DCLD 95) were enrolled. Seventy-seven (47%) had infection. Most common site was ascitic fluid (n = 35), followed by urinary tract (n = 26), pneumonia (n = 22), and blood stream infection (n = 16). Twenty-one children had multiple-site infections, 18 had severe sepsis, and 36 had systemic inflammatory response syndrome. PCT and CRP correlated with infection severity, higher in severe sepsis (8.3 [3.5-38] ng/mL and 4.1 [0.3-13.8] mg/dL) than only infection (0.89 [0.1-8] ng/mL and 1.7 [0.32-24] mg/dL) and no infection (0.3 [0.1-6.75] ng/mL and 0.3 [0.1-4.16 mg/dL]). Systemic inflammatory response syndrome was more common in patients with infection (31/77 vs 5/87, P = 0.00). PCT (0.5 ng/mL) and CRP (0.6 mg/dL) performed better in DCLD (AUC of 0.90 and 0.83) compared with patients with ALF (AUC of 0.73 and 0.69).PCT and CRP are reliable markers of infection and correlate with infection severity in children with liver disease. Their diagnostic accuracy is better in DCLD than ALF cases.

There is a paucity of studies on spectrum of fungal infections in neurology care. This study reports clinical, MRI and outcome of patients with central nervous system (CNS) fungal infections. 39 patients with CNS fungal infections treated in neurology service during the last 3 years were included and a detailed medical history and clinical examination were undertaken. Cranial MRI including paranasal sinuses were carried out and the location and nature of abnormalities were noted. Fungal infection was confirmed by CSF examination or histopathology. Death during hospital stay was noted. The median age was 37 (8-72) years and 8 were females. The clinical features included altered sensorium in 31, focal motor deficits in 13, visual loss in 12, seizures in 10, diplopia in 7, and papilledema in 9 patients. 28 patients had the following predisposing conditions: HIV in 15, diabetes in 8, corticosteroid in 2 and alcohol, immunosuppression, neutropenia and analgesic abuse in 1 patient each. On CT or MRI scan, 5 patients had meningeal enhancement, 7 sinusitis, 10 each granuloma and infarction, 4 hydrocephalous and 1 cerebral venous sinus thrombosis. 28 patients had cryptococcal meningitis, 7 zygomycosis, 2 aspergillosis and 1 each candida and phaeohyphomycosis. Death was related to the type of fungal infection; all patients with zygomycosis and candida infection died. Rhinocerebral form of fungal infection due to zygomycetes has poorer survival compared to meningitis group which was mainly due to cryptococcal infection.

Renal transplant recipients (RTRs) are at increased risk of the development of a variety of skin infections that can result from graft-preserving immuno-suppressive therapy. In this study, we aimed to determine cytomorphological findings of fungal subcutaneous swelling in seven RTRs and to analyze diagnostic pitfalls in fungal cytology. A retrospective review of fine needle aspiration cytology (FNAC) smears of subcutaneous swelling with positive fungal elements in RTRs from 2008 to 2010 was performed. We had seven cases (all males; age range, 34–58 years, mean, 46.3 years). The time interval between the renal transplantation and appearance of swelling ranged from 8 to 19 months (mean, 13.4 months). The swelling was located on lower limb (six cases) and arm (one case). The lesion was solitary (six cases) and multiple (one case). The cytology of aspirated material showed branched septate fungal hyphae in six cases. These were well delineated on Periodic acid schiffs (PAS) and chromic silver methenamine (CSM) stains. One case showed presence of faint, thin walled, broad ribbon like hyphae. Culture of aspirated material was performed in four cases which grew phaeohyphomycosis in all. Histology of excised tissue showed numerous septate, branched, pigmented fungal elements suggestive of pheohyphomycosis in four cases and broad ribbon hyphae suggestive of zygomycosis in one case. All of our cases responded well with anti-fungal treatment. Fungal infection can manifest as subcutaneous swelling in RTRs. It is often severe, rapidly progressive and difficult to diagnose. FNAC is an important diagnostic tool which is simple, cost effective and rapid method. Diagn. Cytopathol. 2012. © 2011 Wiley Periodicals, Inc.

We present two cases of renal zygomycosis caused by Apophysomyces elegans and Mycocladus corymbifer in previously healthy immunocompetent males and an overview of the disease in India. In both cases a percutaneous nephrostomy (PCN) was performed and the etiologic agents were identified by direct microscopy and culture. Amphotericin B was administered and both patients recovered completely. A review of the literature revealed 42 cases of renal zygomycosis in India. The majority of them were from the Postgraduate Institute of Medical Education and Research, Chandigarh, in North India. In contrast to cases from the developed world where transplant recipients and patients with hematological malignancies seem to be most vulnerable to zygomycosis, the most common risk factor in India is uncontrolled diabetes mellitus. However, renal zygomycosis is an exception and the patients in both of our cases had no identifiable underlying disorder and recovered successfully without nephrectomy. It is important to emphasize that treatment of A. elegans must be aggressive and lipid formulations of antifungals are typically favored due to their limited side effects profile and ability of the clinician to use higher doses. A high index of clinical suspicion and knowledge of the varied manifestations in diagnosing this condition cannot be overemphasized.

Nontuberculous mycobacteria (NTMs) are ubiquitous and are being increasingly reported as human opportunistic infection. Cutaneous infection caused by mixed NTM is extremely rare. We encountered the case of a 46-year-old female, who presented with multiple discharging sinuses over the lower anterior abdominal wall (over a previous appendectomy scar) for the past 2 years. Microscopy and culture of the pus discharge were done to isolate and identify the etiological agent. Finally, GenoType Mycobacterium CM/AS assay proved it to be a mixed infection caused byMycobacterium szulgaiandM. intermedium. The patient was advised a combination of rifampicin 600 mg once daily, ethambutol 600 mg once daily, and clarithromycin 500 mg twice daily to be taken along with periodic follow-up based upon clinical response as well as microbiological response. We emphasize that infections by NTM must be considered in the etiology of nonhealing wounds or sinuses, especially at postsurgical sites.

Over past few years, treatment of invasive candidiasis (IC) has evolved from targeted therapy to prophylaxis, pre-emptive and empirical therapy. Numerous predisposing factors for IC have been grouped together in various combinations to design risk prediction models. These models in general have shown good negative predictive value, but poor positive predictive value. They are useful in selecting the population which is less likely to benefit from empirical antifungal therapy and thus prevent overuse of antifungal agents. Current article deals with various risk prediction models for IC and their external validation studies.

A systematic epidemiological study on intensive care unit (ICU)-acquired candidemia across India. A prospective, nationwide, multicentric, observational study was conducted at 27 Indian ICUs. Consecutive patients who acquired candidemia after ICU admission were enrolled during April 2011 through September 2012. Clinical and laboratory variables of these patients were recorded. The present study is an analysis of data specific for adult patients. Among 1,400 ICU-acquired candidemia cases (overall incidence of 6.51 cases/1,000 ICU admission), 65.2 % were adult. Though the study confirmed the already known risk factors for candidemia, the acquisition occurred early after admission to ICU (median 8 days; interquartile range 4–15 days), even infecting patients with lower APACHE II score at admission (median 17.0; mean ± SD 17.2 ± 5.9; interquartile range 14–20). The important finding of the study was the vast spectrum of agents (31 Candida species) causing candidemia and a high rate of isolation of Candida tropicalis (41.6 %). Azole and multidrug resistance were seen in 11.8 and 1.9 % of isolates. Public sector hospitals reported a significantly higher presence of the relatively resistant C. auris (8.2 vs. 3.9 %; p = 0.008) and C. rugosa (5.6 vs. 1.5 %; p = 0.001). The 30-day crude and attributable mortality rates of candidemia patients were 44.7 and 19.6 %, respectively. Logistic regression analysis revealed significant independent predictors of mortality including admission to public sector hospital, APACHE II score at admission, underlying renal failure, central venous catheterization and steroid therapy. The study highlighted a high burden of candidemia in Indian ICUs, early onset after ICU admission, higher risk despite less severe physiology score at admission and a vast spectrum of agents causing the disease with predominance of C. tropicalis.

Pulmonary Mucormycosis is an uncommon disease caused by fungi of class Zygomycetes. It occurs predminantly in an immunodeficient host most common risk factor being diabetes mellitus. The lesions are localized in the lungs or the mediastinum. We are reporting a case of 70 years old male, having cough, haemoptysis, fever and chest pain. He was on antituberculosis treatment (RHEZ) for last 10 days and was later found to have Pulmonary Mucormycosis on further evaluation.

Introduction: Oropharyngeal candidiasis (OPC) is the most common opportunistic fungal infection reported in human immunodeficiency virus (HIV) positive patients worldwide. This prospective study was undertaken to investigate OPC and Candida colonization (CC) and their correlation with CD4+ cell counts and antiretroviral therapy (ART) in HIV-positive patients. Methodology: In total, 190 HIV-positive patients were enrolled for study in three groups as follows: Group A, 90 patients without ART; Group B, 100 patients undergoing treatment with ART; and Group C, 75 HIV-negative control patients. All HIV patients underwent clinical examination and were subjected to CD4+ cell counts. Swabs were collected from the oral cavity of all individuals and plated on Sabouraud’s dextrose agar. Identification of Candida species was performed by conventional methods. Results: Candida species were isolated in 84/190 (44.2%) and 20/75 (26.6%) of the HIV-positive subjects and controls respectively (p 500 cell/mm3 (5/63; 7.9% versus 0/21 0%) respectively. Conclusion: OPC and Candida colonization occur more frequently in HIV-positive patients with CD4+ cell counts ≤200 cell/mm3. ART significantly reduces OPC. C. albicans is the most frequently isolated species in both OPC and colonization, suggesting endogenous infection.

Background: Isolated renal zygomycosis is a life-threatening infection and difficult to diagnose ante mortem due to varied presentations. Most reports in the literature are case reports. We are presenting our experience of 10 patients. Materials and Methods: Retrospective data of 10 consecutive patients with primary renal zygomycosis, including 2 post-transplant patients, in our tertiary care center was analyzed. Epidemiological characteristics, predisposing conditions, clinical presentation, diagnostic findings and treatment outcomes were recorded. Characteristic radiological findings were recorded. Localized disease was managed by supportive treatment or percutaneous drainage and extensive disease with unilateral or bilateral nephrectomy. Renal involvement was confirmed in all patients by histopathology. Results: The mean age of presentation was 35 years. Five patients who had bilateral renal involvement presented with oliguric acute renal failure, hematuria and abdominal pain. Three had unilateral renal disease and presented with flank pain and fever. The two post-transplant patients presented with fever and graft dysfunction. Even after aggressive treatment 5 patients died, accounting for a mortality rate of 50%. Conclusion: Isolated renal zygomycosis can be diagnosed with typical radiological findings, combined with clinical, laboratory and histopathological features. This study describes the newer ante mortem radiological diagnostic criteria and prognostic predictors of the disease.

We report the first two proven cases of cavitary pulmonary zygomycosis caused by Rhizopus homothallicus . The diagnosis in each case was based on histology, culture of the causal agent, and the nucleotide sequence of the D1/D2 region of the 28S ribosomal DNA.

Resistance in Salmonella enterica var Typhi (S. Typhi) to chloramphenicol, amoxicillin and co-trimoxazole has posed a challenge to treatment of typhoid fever. Ciprofloxacin has been the empirical therapy of choice, but the recent increase in minimum inhibitory concentration (MIC) to ciprofloxacin in S. Typhi, not detectable by disc diffusion (DD) tests, may result in delayed response and serious complications. Nalidixic acid (NA) resistance has been used as an indirect evidence of increased ciprofloxacin MIC in S. Typhi. We evaluated the predictive value of NA resistance for fluoroquinolone resistance in clinical isolates of S. Typhi.A total of 70 clinical isolates of S. Typhi were tested for antimicrobial susceptibility according to the National Committee for Clinical Laboratory Standards (NCCLS) method. MIC to fluoroquinolones was carried out by the agar dilution method.Thirteen (18.6 %) isolates were resistant to amoxicillin, chloramphenicol and cotrimoxazole; all were sensitive to ciprofloxacin and cefotaxime. Fifty (71.4%) were resistant to NA. Nineteen (27.1 %) isolates were resistant to ciprofloxacin by MIC tests. The MIC for ciprofloxacin was 0.03-4 microg/ml for NA(S) and 0.25-4 microg/ml for NA(R) isolates. NA susceptibility showed a predictive value of 95 per cent for ciprofloxacin susceptibility while NA resistance had a predictive value of 36 per cent for ciprofloxacin resistance. Thirty isolates studied were sensitive to gatifloxacin; MIC values were 0.03-0.5 microg/ml for NA(S) and 0.25-0.5 microg/ml for NA(R) isolates.NA susceptibility was a good marker for fluoroquinolone susceptibility but NA resistance had a poor predictive value for ciprofloxacin resistance. NA resistant isolates should be tested for ciprofloxacin MIC before deciding a change in therapeutic regimen. Higher MIC for gatifloxacin was also noticed in NA resistant isolates.

Though Chromobacterium violaceum is a common inhabitant of soil and water in tropical and sub-tropical regions, human infections are rare but when they do occur result in high mortality. Since the first case from Malaysia in 1927, about 150 cases have been reported in world literature. Till date 6 cases have been reported from southern and eastern parts of India. We report here a case of C. violaceum septicaemia, probably the first case from north India. The patient, a 6 and a half year old boy was admitted with high fever. The patient had anaemia, neutrophilic leucocytosis and bilateral chest infiltrates. Routine and bacteriological investigations were carried out to establish the aetiological diagnosis. C. violaceum was isolated in pure culture from blood and pus. The patient was successfully treated with ciprofloxacin and amikacin. This is probably the first documented case report of C. violaceum infection from north India and the only Indian case with septicaemia which survived.