We evaluated the usefulness of a serum Aspergillus PCR assay for the diagnosis and prognosis of invasive aspergillosis in a study involving 941 patients for a total of 5146 serum samples. Fifty-one patients had proven/probable aspergillosis. We compared galactomannan (GM), PCR and mycologic analysis of pulmonary samples in both neutropenic and nonneutropenic patients. PCR performed in serum yielded 66.7% sensitivity, 98.7% specificity, 75.6% positive predictive value and 98.0% negative predictive value, while the GM index yielded 78.4% sensitivity, 87.5% specificity, 27% positive predictive value and 98.6% negative predictive value. The inclusion of PCR in the European Organization for Research and Treatment of Cancer (EORTC) and the Mycosis Study Group (MSG) mycologic criteria permitted the reclassification of nine other cases from possible to probable aspergillosis and increased the sensitivity to 71.7%. Combining the GM index with serum PCR increased the detection rate of invasive aspergillosis with 88.2% sensitivity. PCR was systematically negative in 16 patients with noninvasive forms of aspergillosis (namely aspergilloma and chronic aspergillosis). Remaining PCR positive after a period of 14 to 20 days of treatment was related to poor outcome at 30 and 90 days. Our results also indicate that, unlike the determination of the GM index, the initial fungus load as determined by PCR was highly predictive of 90-day mortality, with the rate of the latter being 15.8% for patients with <150 copies/mL vs. 73.2% for patients at or above that cutoff (p <0.0001). Therefore, PCR appears to be a powerful and interesting tool for the identification of patients with invasive aspergillosis who might benefit from more intense care.

We report the case of a fungal mycetoma due to Madurella mycetomatis that failed to respond to surgery and antifungal treatment but responded strongly to the addition of a non, steroidal anti-inflammatory drug (NSAID). This African patient was born in Mauritania in 1972. He was a herdsman, living close to the Senegal River. The first nodules appeared on the left foot at the age of 13 years (1985). The patient suffered frequent flare-ups with the appearance of black grains and underwent surgery in 1988 and 1992 in Senegal. After remission for several months after surgery, new fistulae occurred. The patient emigrated to France in 1995 and underwent a third surgical intervention in 1996. M. mycetomatis was cultured from the black grains. The patient was otherwise in good health, with no diabetes, and HIV tests were negative. We saw the patient for the first time in 2005, at which time he had flare-ups every two to three months. Imaging disclosed an absence of bone involvement. The patient underwent a fourth operation in October, 2005, and voriconazole treatment was initiated. A new flare-up occurred in February, 2006. CT, MRI, and PET scans revealed calcaneus and tarsal involvement, and posaconazole then replaced voriconazole. Flucytosine was added four months later, due to an absence of improvement. New flares-ups occurred and a fifth surgical intervention was performed in September, 2006. The pain, which had been present for three years, worsened; the patient had to stop working and was no longer able to walk without crutches. Amputation of the foot was considered. Empiric treatment with a NSAID, diclofenac (Voltaren (R); 100 mg/day), was added to the antifungal treatment in November 2006, to treat the patient's pain and inflammation. A major improvement was observed within one week. The patient was able to walk without crutches one month later. After two months, clinical examination was normal: no pain, inflammation, nodules or fistulae. Flucytosine was stopped after six months of treatment, in January 2007, diclofenac after 10 months, in October 2007, and posaconazole after 18.5 months, also in October 2007. No relapse has occurred during the eight years of follow-up since treatment ended. The patient seems to have been cured and has normal CT, MRI, and PET scans.In summary. - This eumycetoma, which had progressed over 20 years despite surgery and antifungal treatments, seems to have been cured by the addition of a NSAID. This observation suggests that inflammation plays a major role in the pathogenesis of fungal mycetoma. Clinical studies of treatments including an NSAID should be conducted to confirm this finding. (C) 2016 Elsevier Masson SAS. All rights reserved.

In vitro susceptibility of 933 Candida isolates, from 16 French hospitals, to micafungin was determined using the Etest in each center. All isolates were then sent to a single center for determination of MICs by the EUCAST reference method. Overall essential agreement between the two tests was 98.5% at ±2 log2 dilutions and 90.2% at ±1 log2 dilutions. Categorical agreement was 98.2%. The Etest is a valuable alternative to EUCAST for the routine determination of micafungin MICs in medical mycology laboratories.

BACKGROUND:Neoscytalidium species (formerly Scytalidium species) are black fungi that usually cause cutaneous infections mimicking dermatophytes lesions. Very few publications have reported invasive or disseminated infections.CASE PRESENTATION:In this paper, we report the clinical presentations, treatments and outcomes of five cases of invasive Neoscytalidium infections with cutaneous involvement, including two cases with disseminated infection, in five renal transplant recipients. To our knowledge, this is the first report of a series-albeit small-of renal transplant patients in whom this infection was identified. All cases occurred in a single hospital in Paris, France, between 2001 and 2011. Patients all originate from tropical area.CONCLUSION:Treatments of Neoscytalidium infection varied greatly, underlining the lack of a recommendation for a standardized treatment. All patients were cured after long-term antifungal therapy and/or surgical excision. Interestingly, one patient with disseminated infection involving the left elbow, the right leg, the lungs and the nasal septum was cured by medical therapy only without surgery. This may suggest that in contrast to others mycoses (such as mucormycosis), an adequate medical treatment could be sufficient for treating Neoscytalidium. We also point out the difficulties we had in diagnosing two patients with Kaposi's sarcoma because of the similarity of the lesions. Furthermore, our report underlines the need to check for this rare infection in immunocompromised kidney transplant recipients originating from tropical areas.

Objectives : Micafungin is currently used in France. The aim of this study is to determine its activity against a recent (2014) French collection of Candida isolates. Although EUCAST is the reference method for in vitro antifungal susceptibility testing, it is not commonly used in routine clinical microbiology laboratories. Thus, it is important to evaluate alternative methods. We compared EUCAST and Etest for micafungin susceptibility testing of Candida spp. and we monitored the emergence of resistance. Methods: Sixteen centers (6 in Paris area and 10 across France) participated in a two-months prospective study. Clinical isolates of various Candida species (mainly C. albicans, C. glabrata, C. tropicalis, C. parapsilosis, C. kefyr and C. krusei, about 10 isolates of each species per center) were tested by Etest, according to manufacturer’s instructions. All isolates were subsequently centralized in one center for MIC determination by EUCAST method. For comparison purposes, Etest MICs were raised to the next higher EUCAST concentration. Resistance was defined based on EUCAST clinical breakpoints or on epidemiological cut-off values when clinical breakpoints were not available. Results : A total number of 933 Candida isolates were tested. The overall agreement (+/- 2 log2 dilutions) between EUCAST and Etest was 97.9%. Species n E-Test EUCAST MIC range MIC range % agreement with Etest % resistance C. albicans 159 ≤ 0.015 - 0.06 ≤ 0.015 - 0.06 100 1.3 C. tropicalis 152 ≤ 0.015 - 0.5 ≤ 0.015 - 1 98.7 0.7 C. parapsilosis 152 ≤ 0.015 - 4 ≤ 0.125 - 4 96.1 1.3 C. glabrata 152 ≤ 0.015 - 0.125 ≤ 0.015 - 1 98.7 3.9 C. kefyr 136 ≤ 0.015 - 0.25 ≤ 0.015 - 0.125 97.8 ND C. krusei 127 ≤ 0.015 - 1 ≤ 0.015 - 0.25 96.9 0 Other Candida species* 55 ≤ 0.015 - 1 ≤ 0.015 - 1 94.5 ND Total 933 ≤ 0.015 - 4 ≤ 0.015 - 4 97.9 ND *: C. lusitaniae, C. guilliermondii, C. norvegensis, C. inconspicua, C. famata, C. pelliculosa, C. lambica, C. sphaerica, C. ciferii, C. catenulata, C. utilis, C. colliculosa, C. nivariensis Conclusions : This study demonstrated a very good agreement between Etest, performed on a routine basis, and EUCAST for micafungin MIC determination. Micafungin resistance among the main Candida species was uncommon.

Le diagnostic des aspergilloses invasives (AI) repose le plus souvent sur un faisceau d’arguments comprenant des critères d’hôte, clinique et mycologique, comme ceux définis conjointement par l’European Organisation for Research and Treatment of Cancer (EORTC) et le Mycosis Study Group (MSG). Des publications ont montré l’intérêt potentiel de la détection de l’ADN d’A. fumigatus par PCR (qui n’est à ce jour pas retenue parmi les critères mycologiques). L’objectif de notre travail a été d’évaluer, dans le cadre d’une étude rétrospective monocentrique menée à La Pitié-Salpêtrière, les performances de la PCR aspergillaire sérique pour le diagnostic des AI. Sur une période de 32 mois, une recherche de galactomannane (GM) couplée à une PCR aspergillaire dans le sérum a été effectuée chez 970 patients à risque. Un diagnostic d’AI prouvée/probable selon les critères de l’EORTC/MSG, a été retenu respectivement dans 6 et 44 cas, tandis qu’une forme non invasive d’aspergillose a été diagnostiquée chez 16 patients. Enfin, pour 10 patients, un diagnostic final d’AI a été retenu par les cliniciens alors que seule la PCR était positive. Sur les 50 cas d’AI prouvée/probable selon l’EORTC/MSG, le GM était positif chez 40 patients (80 %), la culture chez 32 patients (64 %) et la PCR chez 33 patients (66 %), dont 4 avec un GM négatif. Parmi les 16 patients qui présentaient une aspergillose non invasive, aucune PCR ni GM ne se sont avérés positifs, seule la culture ou la sérologie permettant d’établir le diagnostic. Enfin, la PCR est revenue positive chez 11 patients pour qui un diagnostic d’AI a été écarté, dont 4 avec un résultat douteux. L’inclusion de la PCR aspergillaire dans les critères mycologiques, permettrait de reclasser 10 épisodes d’AI de possible à probable. Dans cette hypothèse, les sensibilités et spécificités respectives seraient de 71 % et 98,8 % pour la PCR et de 67 % et 88,5 % pour le GM. La PCR semble donc présenter une meilleure spécificité que le GM, cependant, tout comme les autres critères mycologiques, elle continue à manquer de sensibilité, ce qui ne permet pas son utilisation seule dans le diagnostic des AI. La détection de l’ADN sérique circulant d’A. fumigatus par PCR apparaît donc comme outil complémentaire pour l’amélioration du diagnostic d’AI.

Since their introduction in the 2000s, echinocandin drugs have become widely used for the treatment and prophylaxis of invasive fungal infections and, notably, invasive candidiasis. Although cases of breakthrough candidiasis in patients receiving echinocandins have been reported, clinical failure during echinocandin treatment due to the acquisition of resistance by a normally susceptible Candida spp. isolate is considered rare. To date, no publications have been published correlating the use of echinocandins and the emergence of echinocandin resistance among Candida species. So, our goal is to report an initial analysis of echinocandin use in relation to the emergence of resistant Candida isolates. We report here a single-centre experience of the emergence of eight resistant isolates belonging to normally susceptible Candida species in six patients receiving echinocandins. We describe the context and analyse the use of echinocandins over the previous decade. For seven of these isolates, we identified FKS gene mutations involved in decreased susceptibility. Seven isolates were obtained in 2011, on the heels of a ten-fold increase in caspofungin use over the preceding decade. In contrast, in 2012, the use of echinocandins decreased in our institution by 19.5 % and, in that year, only one Candida-resistant isolate was detected, despite the stable global epidemiology of invasive candidaemia. This work underlines the necessity of improving the prescription of antifungal drugs. Improvement in the monitoring of strain susceptibility should also be considered in order to better detect the emergence of resistant or non-susceptible yeast strains.

Voriconazole, itraconazole and posaconazole are members of the azole family and widely used for the treatment of aspergillosis. They act by inhibiting the activity of the fungal Cyp51A enzyme. The emergence of environmental azole-resistant Aspergillus fumigatus strains raises major concerns for human health.Recently, a new cyp51A-mediated resistance mechanism (namely TR46/Y121F/T289A) was described in clinical samples and patient-frequented environmental sites. In an azole-naive patient, we isolated an A. fumigatus strain that was not susceptible to voriconazole but was susceptible to itraconazole and posaconazole.A molecular analysis indicated a single Y121F substitution without the TR46 or T289A alterations, which to our knowledge has never been reported. Structure modelling and molecular dynamics offered an explanation for the resistance profile consistent with the structural differences between the three azoles.Taken together, these observations suggest an original mechanism conferring resistance to azoles mediated by cyp51A of environmental origin. This uncommon susceptibility pattern might represent a 'missing link' between the wild-type A. fumigatus and the fully azole-resistant strain harbouring the TR46/Y121F/T289A mutations.

ABSTRACT Invasive infections caused by filamentous fungi are a major threat for immunocompromised patients. Innate/acquired resistance to antifungal drugs might necessitate combination therapies. We assessed the potential combination of voriconazole with miltefosine, an original drug with antifungal activity against 33 clinically relevant mold isolates, including both azole-susceptible and -resistant Aspergillus . Using complete inhibition as an endpoint, interactions were indifferent for 32/33 isolates. An alternative 50% inhibition endpoint showed synergistic interactions for 14/33 isolates. Antagonism was absent.

Les auteurs rapportent un cas d’ethmoïdite aspergillaire compliquée d’un abcès orbitaire, diagnostiquée chez une enfant âgée de six ans, apparemment immunocompétente. C’est une infection rare, de diagnostic difficile, ce qui retarde la prise en charge et retentit sur le pronostic. L’immunodépression et les voyages outremer constituent des facteurs de risque importants d’infections à agents normalement peu pathogènes et/ou inhabituels, notamment fongiques. La chirurgie avec l’examen mycologique et anatomopathologique du prélèvement évoquera une mycose qui sera confirmée par la culture et contribuera à la prise en charge adaptée.The authors report a case of Aspergillus ethmoiditis associated with an orbital abscess, diagnosed in an immunocompetent 6-year-old child, this is a rare infection and diagnosis is difficult, cause of a delayed treatment and frightening prognosis. Mycoses have emerged as important infections in clinical practice; this phenomenon is explained by the ever-growing number of immunocompromised patients and the increasing number of people traveling in areas where fungal diseases are endemic. Surgery with mycological and anatomopathologic examination can suggest a fungal infection confirmed by culture and contribute to institute adequate treatment.

Mucormycosis is a rare, invasive and fatal disease that occurs mainly in diabetes mellitus patients with uncontrolled blood glucose levels or in immunocompromised patients. The mortality rate of this disease is as high as 25 to 80%, despite aggressive surgical treatment and antifungal therapy. This high mortality requires alternative treatment approaches. The accepted treatment modality of invasive mucormycosis are amphotericin B lipid formulations. Although echinocandins generally show no activity against Mucorales, it was shown that Rhizopus oryzae expressed the target enzyme for echinocandins, 1,3-beta-glucan synthase. Additionally, there are some experimental studies in a diabetic mouse model and case reports regarding the effects of caspofungin. In this report, we present a rhinocerebral mucormycosis case treated with liposomal amphotericin B and caspofungin. There was regression of the patient's clinical and radiological condition with the addition of caspofungin, but she died due to discontinuation of her treatment and reasons other than mucormycosis.La Mucormycose est une maladie rare, invasive et mortelle qui survient principalement chez les patients atteints de diabète avec une glycémie non maîtrisée ou chez des patients immunodéprimés. Le taux de mortalité de cette maladie peut atteindre 25 à 80 %, malgré la mise en place d’un traitement chirurgical et antifongique. Cette mortalité élevée nécessite des approches thérapeutiques alternatives. Le traitement de la mucormycose invasive est classiquement basé sur l’utilisation des formulations lipidiques de l’amphotéricine B. Bien que les échinocandines ne montrent généralement aucune activité contre la classe des Mucorales, il a été montré que Rhizopus oryzae exprime l’enzyme cible des échinocandines, la 1,3-bêta-glucane synthase. En outre, il existe quelques études expérimentales à partir d’un modèle de souris diabétique et des cas rapportés d’activité de la caspofungine. Dans ce travail, nous présentons un cas de mucormycose rhino-cérébrale traité par l’amphotéricine B liposomale et la caspofungine. Il a été constaté une régression des signes cliniques et radiologiques chez ce patient lors de l’adjonction de la caspofungine. Le décès est cependant intervenu en raison de l’interruption de son traitement et de raisons autres que la mucormycose.

ABSTRACT Echinocandin drugs are widely used for the treatment of candidemia. Resistance is considered rare, and only a few cases of breakthrough candidiasis in patients receiving echinocandin have been reported worldwide. We report here for the first time a Candida kefyr isolate that acquired echinocandin resistance very rapidly after the initiation of caspofungin treatment for candidemia. We characterized the FKS gene mutation responsible for the resistance via the comparison of isolates sampled before and during treatment.

Fibrosis, which affects millions of individuals worldwide, is a leading cause of organ failure. For 40 years myofibroblasts have been recognized to be the key cellular players in fibrosis. Currently, several pharmaceutical targets are under investigation that may contribute to the activation of myofibroblasts. Recent preclinical and clinical evidence suggests that other components in the fibrotic microenvironment can trigger myofibroblast activation, providing new targets for pharmaceutical intervention. Epithelial cells may represent the most promising cellular phenotype that could be exploited in the design of new anti-fibrotic medicines through their paracrine action on myofibroblasts. The present review briefly highlights this hypothesis and discusses some interesting related pharmacological targets.

Les dermatomycoses sont des infections dermatologiques très fréquentes en pratique de ville puisqu’elles peuvent atteindre un tiers de la population. Cependant, leur symptomatologie est souvent commune avec d’autres affections ou infections cutanées, et peut être très atypique. Il n’est donc pas possible de poser un diagnostic de certitude par un simple examen clinique. C’est pourquoi le diagnostic mycologique est indispensable pour confirmer ou infirmer une dermatomycose, et ne se discute pas lorsqu’un antifongique systémique doit être proposé comme dans le traitement d’une teigne du cuir chevelu et de la barbe, ou d’une onychomycose. Il devient indispensable lorsqu’un traitement prescrit sur l’aspect clinique des lésions est en échec ou si les lésions cutanées récidivent. La confirmation d’une mycose permet de prescrire un traitement antifongique et la négativité de l’examen justifie d’envisager une autre cause aux lésions observées. Néanmoins, quelle que soit la technique du diagnostic mycologique, la qualité de sa réponse dépend avant tout de la qualité du prélèvement sur le site infecté, mais aussi de l’expertise du biologiste. L’examen mycologique classique demeure le plus informatif, le moins cher, et le seul examen capable d’isoler le champignon responsable quelle que soit la mycose : dermatophytose ; scytalidiose ; infection unguéale à moisissure ; candidose ; infections à Malassezia sp. C’est le seul examen capable d’identifier les variations épidémiologiques. Toutes les autres techniques récemment proposées reposent sur la simple mise en évidence d’éléments fongiques sans identification de l’espèce fongique ou sont dépendantes d’une banque de données de champignons généralement très incomplète.Dermatomycoses are dermatological infections very commonly encountered in private dermatological practice since they affect up to one third of the population. However, the symptoms are very often shared by other skin infections and disorders and may be highly atypical. It is thus impossible to make a diagnosis with any certainty on clinical grounds alone. For this reason, mycological diagnosis is essential to either confirm or rule out dermatomycosis, and is unavoidable when antifungal therapy is required for the treatment of ringworm of the scalp or beard, or for onychomycosis. It is also vital where therapy guided by the clinical appearance of lesions has failed or in the event of recurring skin lesions. Confirmation of mycosis enables antifungals to be initiated and a negative test warrants investigation for other underlying causes for the lesions seen. However, regardless of the mycological diagnostic technique employed, the quality of the results depends chiefly on the quality of sampling of the infected site, but also on the expertise of the microbiologist. Standard mycological testing remains the most informative, the least expensive and the sole examination capable of isolating the causative fungus irrespective of the type of mycosis, such as dermatophytosis, scytalidiosis, mould-induced ungual infection, candidiasis, or infections due to Malassezia sp. This is the only examination able to identify epidemiological variations. All other more recent techniques are either based upon simple demonstration of the fungal elements involved, without identification of the fungal species in question, or else they are reliant upon a fungal database that is generally highly incomplete.

L'ascension croissante des infections fongiques, surtout à levures, avec en parallèle une augmentation de plus en plus nombreuse des résistances aux antifongiques a nécessité la mise en place de tests antifongiques fiables. Les tests de sensibilité des levures aux antifongiques ont montré un défaut de reproductibilité dû à l'absence de directives universellement admises. Les sources majeures de variation des tests de sensibilité sont dues au choix du milieu et de son pH, à la préparation et à la taille de l'inoculum, à la température et au temps d'incubation et à l'évaluation du point final. Ces différents paramètres ont été soumis au “National Committee for Clinical Laboratory Standards” (NCCLS) qui a pu proposer un test de référence (M27.P). Bien que des progrès majeurs et des adaptations à la méthode standard aient été réalisés, il n'existe pas encore à ce jour une bonne corrélation entre les résultats in vitro et les réponses in vivo. Ces tests ne peuvent donc pas être utilisés en microbiologic clinique. Quant aux tests concernant les champignons filamenteux, ils n'en sont qu'à leur balbutiement.Yeast infections are an increasingly important problem and the recognition of antifungal resistance stresses the need for improved susceptibility testing. Antifungal susceptibility testing has lacked reproductibility because of the absence of universally accepted guidelines. The major sources of variation in susceptibility testing have been attributed to the choice of medium and pH, inoculum preparation and size, incubation temperature and time, and end-point criteria. These parameters have been addressed by the National Committee for Clinical Laboratory Standards (NCCLS) and proposed guidelines have recently been published (M27-P). Although major advances in fungal susceptibility testing have been achieved, the results of studies to date do not support a correlation between the results of in vitro susceptibility testing and in vivo response. Routine antifungal susceptibility testing of yeasts should therefore be discouraged. Susceptibility testing of the filamentous fungi is currently poorly developed.

The KEAP1-Nrf2 antioxidant signaling pathway is important in protecting liver from various insults. However, little is known about the expression of Nrf2-related genes in human liver in different diseases.This study utilized normal donor liver tissues (n=35), samples from patients with hepatocellular carcinoma (HCC, n=24), HBV-related cirrhosis (n=27), alcoholic cirrhosis (n=5) and end-stage liver disease (n=13). All of the liver tissues were from the Oriental Liver Transplant Center, Beijing, China. The expressions of Nrf2 and Nrf2-related genes, including its negative regulator Kelch-like ECH-associated protein 1 (KEAP1), its targeted gene NAD(P)H-quinone oxidoreductase 1 (NQO1), glutamate-cysteine ligase catalytic subunit (GCLC) and modified subunit (GCLM), heme oxygenase 1 (HO-1) and peroxiredoxin-1 (PRDX1) were evaluated.The expression of Nrf2 was decreased in HCC, increased in alcoholic cirrhosis and end-stage liver disease. The expression of KEAP1 was increased in all of the liver samples. The most notable finding was the increased expression of NQO1 in HCC (18-fold), alcoholic cirrhosis (6-fold), end-stage liver disease (5-fold) and HBV-related cirrhosis (3-fold). Peri-HCC also had 4-fold higher NQO1 mRNA as compared to the normal livers. GCLC mRNA levels were lower only in HCC, as compared to the normal livers and peri-HCC tissues. GCLM mRNA levels were higher in HBV-related cirrhosis and end-stage liver disease. HO-1 mRNA levels were increased in all liver tissues except for HCC. Peri-HCC had higher PRDX1 mRNA levels compared with HCC and normal livers.Nrf2 and Nrf2-related genes are aberrantly expressed in the liver in different diseases and the increase of NQO1 was the most notable finding, especially in HCC.