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US Outbreak of Fungal Meningitis

March 18 2013

As reported in October 2012, officials in the USA are investigating an outbreak of fungal meningitis and other infections linked to contaminated steroids. At time of writing, a total of 720 cases have been reported in twenty states, with 48 deaths.1 The affected patients received preservative-free methylprednisolone acetate (MPA) epidural injections to treat back or joint pain. Three hundred and two patients presented with spinal infection or abscess at the injection site, 240 with meningitis, 32 with septic arthritis and the remaining patients presented with a combination of conditions. These infections do not transmit from person to person and have been linked to three batches of MPA released since May 2012. The main agent appears to be Exserohilum rostratum, it has been detected in 141 patients as of 14/01/13.1 A further 12 different environmental moulds have been detected in 23 patients. These organisms rarely cause invasive infections in immunocompetent individuals. E. rostratum is a black mould showing elongated, brown, beak-like conidia upon microscopic examination. It is mainly a plant pathogen but has been associated with sinusitis and skin infections. The implicated organisms will grow on standard fungal isolation media but recovery may be poor, the US Centers for Disease Control and Prevention (CDC) have used polymerase chain reaction to aid detection. Meningitis is characterised by fever, chills, headache, neck stiffness, photophobia and vision changes. Onset is invariably sudden for bacterial and viral causes but in this outbreak patients have presented with slowly progressing symptoms (weeks to months after MPA injection). Cerebrospinal fluid (CSF) findings include high protein, low glucose and high neutrophil count. Some patients in this outbreak have suffered strokes due to the fungal infection. Joint infection is characterised by swelling, redness, tenderness and reduced range of movement of the affected joint(s).
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ECDC issues risk assessment on azole resistance in Aspergillus from environmental azole fungicide.

February 28 2013

Today the European Centre for Disease Prevention and Control (ECDC) issued a risk assessment report on azole resistance in Aspergillus spp. and its possible link to environmental usage of azole fungicides. An increase of strains of Aspergillus causing serious human infection showing resistance to azole antifungals has been detected in several European countries although the number of studies is small. However, a high rate of therapy failures has been reported in patients having Aspergillus isolates resistant to triazole antifungals. The majority of resistant isolates are multi-azole-resistant and therefore, triazole drugs would be marginalised in the management of azole resistant aspergillosis. Although the environmental link of the resistance has not been fully proven, there are several findings that point at a relationship.
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New Pan Asia fungal working group

February 19 2013

For the first time a pan-Asia network of fungal expertise has taken root. With nearly half the world’s population in only 3 asian countries (China, India and Indonesia) and many other populous contries, the lack of diagnostic capabilities in Asia is being addressed. The Asia Fungal Working Group (AWFG) was founded to improve the understanding and education, diagnosis and management of fungal diseases in Asia. The AWFG is now under the umbrella of ISHAM. The executive committee of AFWG consists of Professor Arunaloke Chakrabarti (Chandigarh), Professor Yee-Chun Chen (Taipei), Dr Ariya Chindamporn (Bangkok), David Ellis (Adelaide), Ruoyu Li (Beijing), Tan Ai Ling (Singapore), Zhengyin Liu (Beijing), Atul K Patel (Ahmedabad), Pei-Lun Sun (Taipei), Tan Ban Hock (Singapore), Siriorn Watcharananan (Bangkok).
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LIFE advisers meet WHO’s Tuberculosis leader Mario Raviglione

January 22 2013

As Chronic Pulmonary Aspergillosis (CPA) may follow TB in about 10% of cases, discussion on establishment of coordination with the work of the WHO’s STB Department is important. Mario Raviglione, (Director), an Infectious Diseases physician originally from Italy who trained in the USA in Boston and New York in the early AIDS era, described CPA as one the ‘post-TB sequelae’ that had been neglected for too long largely due to lack of information and capacity to diagnose and treat. In detailed discussions, which also included Dr Mukund Uplekar (Policy, Strategy & Innovations team) and Dr Salah Ottmani (Technical Support Coordination team), the need for research and standardization goals were emphasized. Raviglione articulated the value of surveillance and better estimate of the burden as well as of standardization of diagnosis and treatment management to achieve sustained healthcare benefits across different countries and societies. The WHO Global Tuberculosis Report 2012 describes the impact of proper TB care in the past 17 years:20 million lives saved, annual number of TB cases have fallen 2.2% since 2011; and a rapid diagnostic test (GeneXpert) is now available in 67 low- and middle-income countries. The LIFE program should aspire to such uniform, effective and cost-effective approaches.
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Appointment of David Warnock as LIFE advisor

January 14 2013

Fungal disease public health has been greatly strengthened by the work of Dr David Warnock, previously Chief of the Mycotic Diseases Branch at the US Centres of Disease Control. Following his retirement from CDC, Warnock has joined the LIFE Advisory team, bringing with him over 30 years of experience in fungal disease. He has published extensively on the epidemiology, laboratory diagnosis and therapy of fungal diseases. He has quietly and consistently championed the value of epidemiological data and public health tools in better understanding fungal infections, having been the architect of the TransNet study (fungal infection after transplantation) and encouraging the global estimate of cryptococcal meningitis.
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