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• W2885878360 abstract "Invasive fungal infections (IFIs) remain a significant cause of morbidity and mortality among patients with haematological malignancies, with up to 40% attributable mortality [[1]Pagano L. Caira M. Candoni A. Offidani M. Fianchi L. Martino B. et al.The epidemiology of fungal infections in patients with hematologic malignancies: the SEIFEM-2004 study.Haematologica. 2006; 91: 1068-1075PubMed Google Scholar]. Despite antifungal prophylaxis, a combination of more aggressive immunosuppressive therapies, older patients receiving chemotherapy, and improved fungal diagnostics have led to increased recognition of novel pathogens causing IFI. Volvariella volvacea is a filamentous Basidiomycete more commonly known as the straw mushroom. It is an edible fungus and a popular delicacy in East and Southeast Asia. Although Basidiomycetes are environmental fungi that are considered non-pathogenic, they are increasingly recognized as causes of IFI in immunocompromised hosts [[2]Chowdhary A. Kathuria S. Agarwal K. Meis J.F. Recognizing filamentous basidiomycetes as agents of human disease: a review.Med Mycol. 2014; 52: 782-797Crossref PubMed Scopus (52) Google Scholar]. A single case of invasive V. volvacea infection was previously described in the literature [[3]Salit R.B. Shea Y.R. Gea-Banacloche J. Fahle G.A. Abu-Asab M. Sugui J.A. et al.Death by edible mushroom: first report of Volvariella volvacea as an etiologic agent of invasive disease in a patient following double umbilical cord blood transplantation.J Clin Microbiol. 2010; 48: 4329-4332Crossref PubMed Scopus (14) Google Scholar]. We conducted a retrospective review of all adult patients with V. volvacea infections treated between 1 May 2012 and 30 April 2017. A case was defined by identification of V. volvacea on culture from relevant clinical specimens, or direct detection of DNA from sterile site specimens. A total of three patients were identified. One patient had a positive result on direct PCR and sequencing from brain tissue. Two patients were identified based on fungal skin-biopsy cultures. All three patients were ethnic Chinese men living in Southeast Asia, had haematological malignancies, prolonged neutropenia after chemotherapy, clinical and radiological evidence meeting the European Organization for Research and Treatment of Cancer criteria for proven mould infection, with histopathological evidence of angio-invasive hyphal elements (Table 1).Table 1Summary of demographics, clinical presentation, radiological findings and antifungal management of individuals with disseminated Volvariella volvacea infectionPatient 1Patient 2Patient 3Demographics47 years old, Chinese male45 years old, Chinese male64 years old, Chinese maleCountry of originSingaporeMalaysiaChinaMalignancyStage IV A T-lymphoblastic lymphomaAcute lymphoblastic leukaemiaPre-B acute lymphoblastic leukaemiaChemotherapyHyperCVAD (August 2015)FLAG-IDA (March 2016)HyperCVAD (October 2016)Rituximab- hyperCVAD (February 2017)Clinical presentation of invasive fungal disease (days post-chemotherapy)Fever (day 3)Headache and slurred speech (day 27)Facial droop (day 47)Confusion and headache (day 32)Macular skin lesions (day 85)Fever (day 15)Confusion (day 22)Macular skin lesions (day 22)Sites of infectionLung, brainSkin, lung, brainSkin, lung, brainRadiological findingsPulmonary (CT)Mass-like consolidation with multiple nodules associated with ground-glass changesFocal patchy atelectasis with central cavity in right upper lobeNodule with central cavitation in left lower lobeLung consolidation predominantly in the right upper and middle lobes with scattered nodular consolidation remaining lung bilaterallyBrain (MRI)Rim-enhancing mass lesion with perilesional oedema in the lateral aspect of right frontal lobeRing-enhancing nodular lesions in the left cerebral hemisphere and right frontal lobe with variable perilesional oedema and mild left frontal mass effect.Multiple areas of restricted diffusion with mild, smooth peripheral enhancement in both cerebral hemispheres and cerebellum, as well as small areas of leptomeningeal enhancementHistological findingsLung: Septated fungal hyphae formsBrain: Septated fungal hyphae with occasional irregular branching, some hyphae surrounding and invading vessel wallsBrain: Reactive changesSkin: Broad-appearing pauci-septate hyphae, seen within blood vesselsSkin: Broad pauci-septate hyphae, lying within and around dermal blood vesselsβ-d-glucan--CSF >500 pg/mLGalactomannanBAL 0.1, Serum 0.1, CSF 0.0BAL 0.3, Serum 0.1BAL >5.0, Serum >5.0, CSF 0.1Aspergillus PCRBAL, lung tissue and CSF negativeBrain tissue and CSF negativeCSF and BAL negativeDiagnosis confirmed by:Direct PCR and sequencing of internal transcribed spacer from brain biopsyCultureCultureAntifungal prophylaxisNilPosaconazoleNilAntifungal treatment summaryVoriconazole, followed by addition of LAmbThen maintained on oral voriconazole due to renal impairmentVoriconazole, followed by addition of LAmbVoriconazole followed by addition of LAmbOutcome (days from onset of symptoms)Survived infection but died 5 months later of an intracranial eventDied (day 59)Died (day 32)BAL, bronchoalveolar lavage; CSF, cerebrospinal fluid; CT, computed tomography; LAmb, liposomal amphotericin B; MRI, magnetic resonance imaging; PCR, polymerase chain reaction. Open table in a new tab BAL, bronchoalveolar lavage; CSF, cerebrospinal fluid; CT, computed tomography; LAmb, liposomal amphotericin B; MRI, magnetic resonance imaging; PCR, polymerase chain reaction. All three patients had pulmonary and brain lesions and remained profoundly neutropenic during their IFI. Bronchoalveolar lavage samples from all patients were negative on cultures for aerobic and anaerobic bacteria, fungi and mycobacteria. Galactomannan was positive from both bronchoalveolar lavage and serum in patient 3, but as it has not been described in the cell wall of V. volvacea, the positive result in patient 3 was most likely a false positive from piperacillin-tazobactam therapy. Histological specimens from lung and brain biopsy from patient 1 showed fungal elements, but both were again culture negative. The pathogen was identified by direct PCR and sequencing performed on brain tissue for patient 1. The final diagnosis for patients 2 and 3 was obtained from skin biopsies (right thigh and right flank, respectively), which showed histological evidence of invasive mould infection with features suggestive of Mucormycosis. Cultures from both skin biopsies instead yielded V. volvacea. Fungus cultures were performed on Sabouraud dextrose medium with chloramphenicol (bronchoalveolar lavage and skin biopsy), and without chloramphenicol (brain and lung biopsies), incubated at 30°C and 37°C. Brain biopsy tissue was cultured on Sabouraud dextrose slant (30°C) and brain–heart infusion slant (37°C). All fungus cultures were incubated up to 21 days. Growth was first detected on day 4 (patient 3) and day 10 (patient 2) after inoculation. DNA extraction from unpreserved brain biopsy was performed using DNeasy blood & tissue kit (Qiagen, Hilden, Germany) for patient 1. UltraClean®Microbial DNA Isolation Kit (MO BIO Laboratories, Carlsbad, CA, USA) was used to extract DNA from fungal colonies for patients 2 and 3. Molecular confirmation of identification was performed as previously described [[4]White T.J. Bruns S. Lee S. Taylor J. Amplification and direct sequencing of fungal ribosomal RNA genes for phylogenetics.in: PCR protocols: a guide to methods and applications. 1990: 315-322Crossref Google Scholar]. Sequence analysis showed that the internally transcribed spacer regions amplified from the brain tissue of patient 1, and of both V65 (patient 2) and V57 (patient 3) were 100% identical to V. volvacea strain OE-55 (GenBank Accession no. KC142119). The highly conserved V. volvacea mitochondrial intermediate peptidase gene was also PCR-amplified and sequenced for available isolates for confirmation of identification [[5]Chen B.-Z. Gui F. Xie B.-G. Zou F. Jiang Y.-J. Deng Y.-J. Sequence and comparative analysis of the MIP gene in Chinese straw mushroom, Volvariella volvacea.Genome. 2012; 55: 667-672Crossref PubMed Scopus (4) Google Scholar]. Inter-simple-sequence repeat-PCR typing indicated that the two cultured isolates were genetically different (see Supplementary Material, Fig. S1) [[6]Sahoo A.K. Mohapatra K.B. Behera B.B. Jadhao K.R. Rout G.R. Phylogenetic analysis of high yielding strain of paddy straw mushroom (Volvariella volvacea) by using ISSR markers.Middle-East J Sci Res. 2014; 21: 1197-1202Google Scholar]. All patients had liposomal amphotericin B added following progression of infection despite treatment with empiric voriconazole therapy. Only patient 1 survived this infection. He was continued on oral voriconazole for 5 months with reduction in the size of the brain lesions before succumbing to an intracranial bleed contralateral to the fungal abscess. Testing of the MIC was performed by broth microdilution using YeastOne Sensititre® (YO10 plates; Thermo Fisher Scientific, Waltham, MA, USA) as per the manufacturer's instructions. The MICs for the isolate V65 were as follows: fluconazole >64 mg/L, voriconazole 0.5 mg/L, itraconazole 0.12 mg/L, posaconazole 0.5 mg/L, flucytosine 128 mg/L, anidulafungin >8 mg/L, micafungin >8 mg/L, caspofungin >8mg/L, amphotericin B 2 mg/L. The MICs obtained were high for flucytosine, the echinocandins and fluconazole, suggesting that these agents are probably ineffective, similar to the previously reported case [[3]Salit R.B. Shea Y.R. Gea-Banacloche J. Fahle G.A. Abu-Asab M. Sugui J.A. et al.Death by edible mushroom: first report of Volvariella volvacea as an etiologic agent of invasive disease in a patient following double umbilical cord blood transplantation.J Clin Microbiol. 2010; 48: 4329-4332Crossref PubMed Scopus (14) Google Scholar]. However, isolate V65 had a lower MIC to voriconazole and posaconazole, but a higher MIC to amphotericin B. The results were also similar to reported MICs for other Basidiomycetes with high MICs for echinocandins, whereas MICs to mould-active azoles and amphotericin B were more variable [[2]Chowdhary A. Kathuria S. Agarwal K. Meis J.F. Recognizing filamentous basidiomycetes as agents of human disease: a review.Med Mycol. 2014; 52: 782-797Crossref PubMed Scopus (52) Google Scholar]. However, correlation between antifungal MIC and clinical outcomes in invasive mould infections has not been clearly established. Subsequent attempts to obtain pure cultures of isolate V57 by reviving stored cultures were not successful because of contamination by a separate mould hence susceptibility testing could not be performed. Filamentous Basidiomycetes were previously dismissed as laboratory contaminants but they are now reported to cause conditions such as allergic fungal sinusitis, fungal pneumonia, fungaemia and brain abscesses. Here, we described V. volvacea infection as a pathogen among Asian patients with haematological malignancies, causing invasive fungal infections with a high mortality. A detailed dietary history was not available to determine whether dietary exposure could be implicated as a potential route of transmission. The previously reported case occurred in a patient of Indian ethnicity living outside Southeast Asia. Although more cases are expected in regions where straw mushroom cultivation and consumption are more prevalent, infections in other regions may occur with globalization and increasing worldwide travel. Identification and accurate characterization of novel pathogens is key to guide early initiation of appropriate antifungal therapy to optimize outcomes for these vulnerable patients. The authors declare that they have no conflicts of interest. This project was reviewed and approved by the National Healthcare Group Domain Specific Review Board (NHG DSRB ref. no. 2017/00358). Requirement for consent was waived by the National Healthcare Group Domain Specific Review Board (NHG DSRB Reference number: 2017/00358). No specific funding was used for performing this study." @default.
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• W2885878360 title "Disseminated Volvariella volvacea infections in patients with haematological malignancies: a case series" @default.
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