INTRODUCTION:Wickerhamomyces anomalus is an emerging pathogen in Indian hospitals, with limited data on antifungal resistance and its clinical impact. We aimed to explore its antifungal susceptibility, clinical outcomes, resistance mechanisms and molecular epidemiology. MATERIALS AND METHODS:Seventy clinical isolates of W. anomalus (2016-24) were collected from PGIMER, Chandigarh (n = 29), BHU, Varanasi (n = 33), and AIIMS, New Delhi (n = 8). Antifungal susceptibility testing (AFST) was done for amphotericin B, fluconazole, voriconazole, itraconazole, posaconazole, caspofungin, anidulafungin and micafungin. ERG11 sequencing, ERG11, MDR1 and CDR1 expression analysis (RT-qPCR), biofilm formation, ergosterol content and genetic relatedness [short tandem repeat (STR) typing] were performed. RESULTS:The AFST (n = 70) showed that 72% isolates were non-wild-type (NWT) for fluconazole, 17% cross-resistance with voriconazole, and 1.4% with micafungin. Among fungemia cases, 53.2% occurred in neonates. Respiratory distress syndrome was the most common associated comorbidity, 26/62 (41.9%), with mortality in 31/62 (50%). ERG11 sequencing revealed four non-synonymous mutations, N41K, R420K, P485L, and T486K(novel), in 28 (55%) NWT isolates. Gene expression analysis revealed upregulation of ERG11 (12.72-fold) and CDR1 (3.08-fold) in NWT isolates without ERG11 mutations. Biofilm formation was higher in NWT versus wild-type. STR genotyping revealed 22 genotypes and 5 clusters (≥3 isolates), suggesting clonal transmission. CONCLUSION:This multicentre study demonstrates the emergence of fluconazole-NWT W. anomalus in Indian hospitals, predominantly affecting neonates, with a high mortality. Resistance was associated with ERG11 mutations, efflux pump overexpression and biofilm formation. These findings highlight that the drug-resistant W. anomalus fungemia is an emerging concern.

Nocardia mainly affects immunocompromised individuals. We report a case of immunocompetent male, with neurological complaints for the past eight months. Contrast-enhanced MRI (CE-MRI) revealed space-occupying lesion with frontal lobe abscess. The patient underwent craniotomy, and pus was sent for microbiological diagnosis. Direct KOH-calcofluor white mount, and modified Ziehl-Neelsen (ZN) staining demonstrated thin, branching filamentous structures suggestive of Nocardia spp. Nocardia brasiliensis was confirmed through 16S rRNA sequencing. The patient received targeted antimicrobial therapy. Direct fluorescent microscopy is an important initial investigation in the diagnostic workup. Early diagnosis and appropriate management is key to favorable clinical outcomes in cerebral nocardiosis.

A 61-year-old woman presented with progressive shortness of breath, cough with expectoration, hemoptysis, and fever for 2 months. On admission, altered parameters included low oxygen saturation, slightly elevated total leukocyte count, and elevated bilirubin and liver enzymes. Contrast-enhanced computed tomography of the chest revealed bilateral cystic bronchiectasis with multiple cavitary nodules. Ultrasonography of the abdomen revealed extrahepatic biliary obstruction, likely carcinomatous in etiology. She was started on antibiotics and percutaneous transhepatic biliary drainage was done. The patient had to be intubated owing to worsening respiratory function. Antifungals were added subsequently due to raised galactomannan levels, but the patient died due to refractory hypokalemia. Postmortem lung biopsy sample showed septate hyphae on direct microscopy. The culture of the mini-bronchoalveolar lavage sample, as well as postmortem lung biopsy, grew a dematiaceous mold. Sequencing of the internal transcribed spacer region of the 18S ribosomal DNA identified the isolate to be Acrophialophora angustiphialis.

SETTINGS:Identification of the prevalent species and report clinical features, predisposing factors, and visual outcomes of ocular infections caused by Scedosporium/Lomentospora in a tertiary care eye centre North India. PATIENT/STUDY POPULATION:During a study period of 9 months from December 2022 to August 2023, eight cases of culture positive Scedosporium/Lomentospora ocular infections diagnosed were included in the study. OBSERVATION PROCEDURE:Definitive diagnosis was established on clinical suggestion of fungal infection along with microscopic findings and culture isolation of the fungal pathogen from clinical specimens. The main parameters assessed included predisposing (risk) factors, clinical characteristics, treatment modality used, and visual sequel of individual patients. Time to healing was stated as the time interval from beginning of clinical symptoms to the follow up visit when antifungals were stopped (absolute scarring of infiltrate). OUTCOME MEASURES:Of included eight cases, Scedosporium apiospermum was identified in five cases (including teleomorph state Pseudallescheria boydii and Graphium form) and Lomentospora prolificans was identified in three cases. The mean time to presentation at our hospital from the commencement of clinical disease was 19.2 days (range 1-30 day). History of trauma was present in five (83.3%) of six patients. Different clinical presentations predominantly included keratitis followed by endophthalmitis. Two cases (culture positive Lomentospora prolificans) with provisional diagnosis of fungal keratitis presented with complete corneal melt. Medical management alone with natamycin was successful in two cases, while other patients required surgical intervention in addition to medical management. Scleral involvement and vitreous involvement were associated with poor prognosis. The average time to healing in noted in our series was ~ 90 days. Thus, prompt diagnosis is critical for commencing targeted antifungal therapy as these fungi are resistant to many antifungal agents. Oral and topical antifungals along with surgical management (therapeutic penetrating keratoplasty) were successful for the treatment of S. apiospermum/L. prolificans oculomycosis involving the posterior segment of the eye.

Abstract Background Post-mortem studies have shown significant underestimation of invasive pulmonary aspergillosis in critically ill ICU patients, in resource-limited settings due to limited awareness, diagnostic capabilities, and ubiquitous presence of Aspergillus spores. The revised BM AspICU algorithm for critically ill patients was validated in a historical cohort, with changes in the host and imaging criteria as well as inclusion of PCR assays. This study for the first time prospectively evaluated the utility of the criteria in a cohort of ICU patients, using post-mortem minimally invasive tissue sampling.Figure 1.Study methodology (Prospective validation of BM Asp ICU clinical algorithm) Patients on mechanical ventilation with a host risk factor, clinical or imaging sign or Aspergillus growth from lower respiratory tract were recruited as per the BM-Asp ICU algorithm . All patients underwent blood and bronchoalveolar lavage fluid Aspergillus PCR on Day 0, 6 and 12 and biomarker (galactomannan) estimation in blood and lavage fluid every third day till death/recovery from illness. The analysis was done on patients who expired and post-mortem minimally invasive tissue samples could be obtained for PCR, KOH staining, and culture and histopathology. Methods Patients on mechanical ventilation with a host risk factor, clinical or imaging sign or Aspergillus growth in lower respiratory tract were recruited (Figure 1). All patients underwent blood and bronchoalveolar lavage fluid Aspergillus PCR and biomarker (Galactomannan) estimation in blood and lavage fluid till death/recovery from illness. Post-mortem MITS was done to obtain samples for histopathology, KOH staining for hyphae and culture and Aspergillus PCR to enable classification as definite IPA/not as per the revised algorithm.Figure 2Host risk factors in study population Results A total of 135 patients were included, out of whom 99 expired. MITS was done in 66 patients, allowing classification as definite IPA or not. The mean age was 43+16 years with 47% males (n=66). 21% (n=14) had an EORTC risk factor while of the remaining, 98% (n=51) had a non-EORTC risk factor for IPA (Figure 2). The overall tests characteristics for the BM Asp ICU clinical algorithm showed a sensitivity of 84.5% [95% CI (72.6-92.6)], specificity of 42.9% [95% CI (9.9-81.6)], PPV of 92.4% [95% CI (86.5-95.9)] and NPV of 25% [95% CI (10.5-48.7)]. The test performance of biomarker compared poorly when compared to PCR in blood and BAL samples (Figure 3).Figure 3Study results Conclusion The revised BM Asp ICU clinical algorithm caters to non-neutropenic critically ill patients in ICU, under-recognised by the EORTC MSG criteria. This first-of-its-kind prospective study shows moderate sensitivity in a high prevalence setting, indicating a possible need for further modifications to ensure timely recognition of IPA. Biomarkers compared poorly when compared to PCR overall, with BAL PCR performing better as compared PCR testing in blood samples. Disclosures All Authors: No reported disclosures

Background and Purpose:Invasive candidiasis (IC) in the hospitalized population is one of the leading causes of invasive fungal infections (IFIs). Microbiological diagnosis of IC suffers due to poor sensitivity of blood culture and relative inaccessibility to more sensitive modalities. (1, 3)-β-D-glucan (BDG) is a cell wall polysaccharide found in a range of fungi. Various commercial assays are available based on various detection techniques. This study aimed to assess the diagnostic performance of the FungiXpert® Fungus BDG Detection Kit by Genobio Pharmaceutical Co. Ltd. (Tianjin, China), based on chemiluminescent method, for diagnosis of candidemia and deep-seated candidiasis. Materials and Methods:In total, 80 patients (34 males and 46 females) were included with a median age of 35 years old. In accordance with EORTC/MSGERC definitions, 39 patients had proven IC. The number of patients within the probable, possible, and no IC (taken as control) groups were 8, 4, and 29, respectively. Blood samples were collected for fungal blood culture and BDG assay. Results:After exclusion of cases with evidence of concurrent IFI other than IC, median serum BDG was 0.63 ng/ml for proven IC; while it was 0.04 ng/ml for NO IC. Sensitivity, specificity, positive, and negative predictive values were 60.52%, 81.81%, 85.18%, and 54.54%, respectively. Positive likelihood ratio was 3.32. While the assay performed best for Candida tropicalis with median BDG of 1.92 ng/ml and sensitivity of 92.3%, its performance was worst for Candida parapsilosis, with median BDG of 0.04 ng/ml and sensitivity of 44.44%. Overall mortality rate was 65.62% in the BDG positive group, which was significantly higher than that in the BDG negative group (33.33%). Conclusion:The performance of the FungiXpert® Fungus BDG Detection Kit was acceptable for invasive candidiasis in the present resource-limited setup. The major advantages of this assay were the ease of performance in a semi-automated cartridge format, relatively lower cost per test, non-reliance on glucan-free procedures or instruments and minimal hands-on procedure.

Aim: To assess the incidence of comorbidities and opportunistic infections (OIs) in advanced HIV. Design: This is a prospective observational study conducted on people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLHA) with a laboratory-confirmed cluster of differentiation-4 (CD4) counts <100/mm 3 . Recruitment of 102 PLHA patients was performed with no filtering criteria based on the duration of diagnosis, antiretroviral therapy (ART) naive, or ART failure. Data collection was initiated post-clearance by the Institutional Ethics Committee. Methods: The study was conducted at the tertiary care center. The prevalence of underlying comorbidities and the incidence of multiple OIs were assessed in 102 HIV patients with CD4 <100/mm 3 . A detailed clinical examination was carried out, and all relevant investigations were digitally recorded. Results: The mean age of the participants among the 102 PLHA with a CD4 count of 100/mm 3 was 41.4 + 11.2 years, and their mean CD4 count was 62.3 + 20.5/mm 3 at the time of recruitment. A total of 62 (60.8%) patients were ART-naive. The two most prevalent comorbidities in the research population were anemia and renal failure. Fungal infections (66.6%) in the study cohort varied from the most frequent oral thrush (42.1%) to disseminated histoplasmosis (7.8%). Tuberculosis was the second most prevalent opportunistic illness (36.2%). Syphilis cases were prevalent (8.8%) among sexually transmitted illnesses linked to HIV, with most of the cases being latent syphilis; 3.9% of the patients were coinfected with chronic hepatitis B and HIV, and only one possessed chronic hepatitis C. Conclusion: Comorbidities and OIs are major public health concerns in Indian healthcare settings. Our findings show that the prevalence of comorbidities and OIs is high. Furthermore, late diagnosis with HIV, a CD4 count <100/mm 3 , and poor adherence indicate an increased incidence and decreased survival time among PLHA with underlying comorbidities and OIs . Early care-seeking and the beginning of ART, as well as ongoing monitoring of patients to ensure they take their medication on schedule, are critical to reducing OIs and improving general health. Further research is highly recommended to gain deeper insights.

PURPOSE:This study was planned to determine the trends and susceptibility pattern of invasive pulmonary aspergillosis (IPA) in severely ill chronic obstructive pulmonary disease (COPD) patients admitted in pulmonary ward and ICU of our tertiary care centre.METHODS:Fifty COPD patients suspected of IPA from pulmonary ward and ICU from April 2017 to September 2018 were investigated. Samples were processed by standard methods, culture positive isolates were confirmed by MALDI-TOF MS and antifungal susceptibility testing was performed by microbroth dilution method.RESULTS:Twenty-two critically ill COPD patients were microbiologically positive for IA infection, of which 13 were classified as putative invasive aspergillosis. The most common comorbid illness associated was diabetes. A. flavus and A. fumigatus were the commonest species isolated. The minimum inhibitory concentration of the antifungals was low. Morbidity due to IPA in COPD patients was very high.CONCLUSIONS:Prevalence of IPA in the pulmonary ward and ICU was found to be 9.6%. MALDI-TOF seems to be a promising tool for aiding rapid identification especially for slow growing and non-sporulating fungi. Heightened awareness and suspicion for pulmonary mould infections along with early diagnosis can substantially alter the patient prognosis.