Asia Fungal - AFWG · Medical Mycology Training Network, to provide microbiolo-gists and clinicians...

Newsletter Issue 1 • January 2013

Working GroupAsia Fungal

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Committed to education and best practice in mycologyThe Asia Fungal Working Group (AFWG) was established in 2009 with the aim to improve the understanding, diagnos-tics and management of invasive fungal diseases in Asia. The AFWG is committed to facilitating exchange of informa-tion and skills among professionals in medical mycology and expanding the fungal surveillance and clinical data to support best practices in Asia. It is now a working group under the umbrella of the International Society for Human and Animal Mycology (ISHAM).

The AFWG is proud to be led by the executive committee members, who are experts in the field of medical mycology

and infectious disease from six countries across Asia. Each of the executive committee members has an ongoing commitment to education and to improving the diagnosis and management of fungal diseases in the region. Together, they represent a wealth of clinical expertise and experience, and will continue to pursue the commitments of the working group through a range of initiatives. The AFWG is also taking the initiative to incorporate experts in the same field from other countries so that the group can be representative of Asia.

Commitment to educationAs part of the commitment to education, the AFWG has

organized a successful series of educational workshops, the Medical Mycology Training Network, to provide microbiolo-gists and clinicians in Asia with the relevant skills in laboratory-based diagnosis and clinical management of medical mycoses. The Medical Mycology Training Network is on its third year running and has successfully trained more than 150 health professionals from across Asia to date. The program has benefited from the lead of its convener, Professor David Ellis (Women’s and Children’s Hospital, Adelaide, Australia), as well as from the contributions from many inter-national and Asian speakers and facilitators.

Introducing the Asia Fungal working Group

Speaker and participants of the 2011 Medical Mycology Training Network in Phuket, Thailand



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Commitment to studies and surveillance Understanding the value of fungal surveillance data to support best-practice fungal management in Asia, the AFWG has carried out a multicenter, laboratory-based, retrospec-tive surveillance study to determine the epidemiology of fungal infections in Asia. The study involved 25 centers from six countries/regions in Asia and the results show distinct epidemiology and interesting geographic variations in fungal burden in different Asian regions. Results of the study were presented at the 18th ISHAM Congress 2012 in Berlin, Germany.

About the newsletterThe AFWG Newsletter is a new opportunity to contribute to improving the management of fungal infections in Asia by presenting relevant information on management practice and acting as a forum for experience-sharing among healthcare professionals in the region. We hope to gain support from readers across Asia for this inaugural issue and future issues to expand the content and maximize the newsletter’s potential. Collectively, we will continue to work towards the overarching goal of ensuring timely diagnosis and effective treatment of fungal infections in Asia.

Arunaloke Chakrabarti ProfessorCenter for Advanced Research in Medical Mycology & WHO Collaborating Center Postgraduate Institute of Medical Education & ResearchChandigarh, India

Yee-Chun Chen Professor, Department of MedicineNational Taiwan University College of MedicineDirector, Center for Infection ControlNational Taiwan University HospitalTaipei, Taiwan

Ariya ChindampornAssociate ProfessorDepartment of MicrobiologyFaculty of MedicineChulalongkorn UniversityBangkok, Thailand

David EllisAssociate ProfessorSchool of Molecular & Biomedical ScienceThe University of AdelaideEmeritis MycologistSA Pathology at Women’s and Children’s Hospital Adelaide, Australia

Ruoyu Li Professor and ChairDepartment of DermatologyPeking University First HospitalPeking UniversityBeijing, China

Tan Ai LingSenior ConsultantDepartment of PathologySingapore General HospitalSingapore

Zhengyin Liu Professor, Infectious Disease SectionDepartment of Internal MedicinePeking Union Medical College HospitalBeijing, China

Atul K PatelChief ConsultantInfectious Diseases ClinicVEDANTA Institute of Medical SciencesAhmedabad, India

Pei-Lun SunAttending Physician Department of DermatologyMackay Memorial HospitalTaipei, Taiwan

Tan Ban Hock Head, Department of Infectious DiseaseSingapore General Hospital Singapore

Siriorn WatcharanananAssistant Professor of MedicineSection of Infectious DiseaseDepartment of Internal MedicineFaculty of MedicineRamathibodi HospitalMahidol University Bangkok, Thailand

AFwG executive Committee



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One fungus, one name (Penicillium marneffei now talaromyces marneffei)Professor David Ellis

At the International Botanical Congress held in Melbourne in July 2011, sweeping changes were made to the Code of Nomenclature that governs the naming of fungi. As a result, fungal taxonomy and nomenclature are currently undergoing a particularly complex period of change, primarily due to the removal of Article 59, which permitted the use of both teleo-morph and anamorph names for fungal species. From January 2013, fungi will be allowed only one name and the transition to the ‘one fungus, one name’ system for all current fungal species with multiple names, ie, teleomorph and anamorph forms, will have to be carried out. Approximately 2,000 genus and 10,000 species names will need to be reassessed. This will take several years of consultation between many groups. Not all names will necessarily change and it is expected that many medically important species’ names will be conserved regardless of nomenclatural priority. (See Hawksworth DL. A new dawn for the naming of fungi: impacts of decisions made in Melbourne in July 2011 on the future publication and regulation of fungal names. MycoKeys 2011;1:7-20.)

Accordingly, the genus Penicillium has now been revised. Essentially, the anamorphic genus Penicillium has two teleomorphic genera – Eupenicillium and Talaromyces. The biverticillate species of Penicillium have now been incorpo-rated into the genus Talaromyces. The remaining Penicillium/Eupenicillium species have been incorporated into the genus Penicillium. (See Samson RA et al. Phylogeny and nomen-clature of the genus Talaromyces and taxa accommodated in Penicillium subgenus Biverticillium. Stud Mycol 2011;70: 159-183. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3233910/)

Talaromyces marneffei (Segretain, Capponi & Sureau) Samson, Yilmaz, Frisvad & Seifert, comb. nov. MycoBank MB560656. Basionym: Penicillium marneffei Segretain, Capponi & Sureau apud Segretain, Bull. Soc. Mycol. France 75: 416. 1959 [1960].

Talaromyces funiculosus (Thom) Samson, Yilmaz, Frisvad & Seifert, comb. nov. MycoBank MB560653. Basionym: Penicillium funiculosum Thom, Bull. Bur. Anim. Ind. U.S. Dep. Agric. 118: 69. 1910.

Talaromyces purpurogenus (Stoll) Samson, Yilmaz, Frisvad & Seifert, comb. nov. MycoBank MB560667. Basionym: Penicillium purpurogenum Stoll, Beitr. Charakt. Penicillium-Arten: 32. 1904.

Fungal meningitis outbreak makes news headlinesProfessor David Ellis

Recent news headlines in the United States have reported an outbreak of fungal meningitis caused by Exserohilum rostratum. To date, 541 cases of meningitis and 33 deaths have been reported from 19 states. This outbreak was linked to the use of contaminated injectable steroids. The Centers for Disease Control and Prevention (CDC) and state health departments estimate that approximately 14,000 patients may have received injections with medication from the three implicated lots of methylprednisolone. (Visit www.cdc.gov/HAI/ for more information.)

Colonies of E. rostratum are grey to blackish-brown, suede-like to floccose in texture, and have an olivaceous black reverse. Conidia are straight, curved or slightly bent, ellipsoidal to fusiform, have a strongly protruding, truncate hilum, and the septum above the hilum is usually thickened and dark.

Exserohilum species are common environmental molds found in soil and on plants, especially grasses. Several species have been reported as agents of phaeo-hyphomycosis, notably E. rostratum, E. meginnisii and E. longirostratum. Clinical manifestations include mycotic keratitis, subcutaneous phaeohyphomycosis, endocarditis, osteomyelitis, sinusitis and now meningitis in both normal and immunosuppressed patients.

MYCOLOGY NEWS

Conidia of Exserohilum rostratum



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Fungal epidemiology in Asia: New insights from regional surveillance

Dr Pei-Lun Sun Department of DermatologyMackay Memorial Hospital Taipei, Taiwan Presented on behalf of the AFWG

The increasing incidence of fungal infections, as a result of the rising elderly and immunocompromised populations, combined with the increasing number of challenging fungal pathogens being identified, have called for the need for large-scale surveillance data on global and Asian fungal infections.

Results from the recent retrospective, observational, laboratory-based surveillance study initiated by the AFWG were presented. The primary objective of the study was to determine the epidemiology of fungal pathogens in Asia.1,2 The study involved emergency services and outpatient and inpatient clinics from 25 centers in six countries/regions

in Asia. Secondary objectives of the study included deter-mining the distribution of fungal pathogens by geography and the relative frequency of fungal pathogens in specific clinical specimens, as well as surveying practice standards of different medical mycology laboratories.

Between July 2010 and June 2011, data were collected from more than 1.1 million medically attended patients in China (10 hospitals), Hong Kong (1 hospital), India (4 hospi-tals), Singapore (1 hospital), Taiwan (6 hospitals) and Thailand (3 hospitals). Overall, more than 50,000 non-duplicated fungal isolates were analyzed. Yeasts made up 85% of speci-mens, followed by molds (11%), dermatophytes (4%) and dimorphic fungi (0.16%). The fungal burden, as illustrated by the incidence of candidemia, and mycology laboratory practices, as reflected by the proportion of species identified, varied markedly between countries (Table).1

While the proportion of Candida tropicalis among all Candida isolates from blood samples is low in Europe (2% in Sweden, Belgium, Italy and Switzerland), this ranged from 11% to 43% in the Asian countries included in this study. Within Asia, the proportions of C. tropicalis were higher

the AFwG session at IsHAM 2012, Berlin, GermanyAs part of the 18th ISHAM Congress program, representatives of the AFWG reported on updated findings and ongoing initiatives to facilitate improved diagnosis and management of fungal infections in the Asia-Pacific region, with an aim to optimizing clinical practice and care. One such initiative is the development of a retrospective surveillance study to establish the epidemiology of fungal infections in the region, results of which were presented at a symposium dedicated to Asian fungal infections at ISHAM 2012. The session was chaired by Professor Yee-Chun Chen from Taipei, Taiwan, and Professor Ruoyu Li from Beijing, China.

CONFERENCE HIGHLIGHTS

Table. Fungal burden and mycology laboratory practices in Asian countries1

Country Incidence of candidemiaPercentage of genus

identificationPercentage of species identification

Per 1,000 patient

discharges

Per 1,000 patient days

Among all yeasts

Among all molds

Among all Candida

blood isolates

Among all Aspergillus

spp.

Among all zygomycetes

China 0.38 0.11 98.52 96.70 94.53 65.33 5.41

Hong Kong 0.25 0.07 99.96 92.80 100 83.03 0

India 1.94 N/A 84.63 100 89.19 86.04 70.37

Singapore N/A 0.15 100 65.76 99.33 81.31 0

Taiwan 3.15 0.36 74.71 73.14 98.77 66.99 22.22

Thailand 2.61 0.38 99.25 95.91 100 92.52 9.09N/A, not available



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among tropical countries (eg, India, Singapore, Thailand) than in subtropical or temperate zones (eg, Hong Kong, Taiwan). The type of Aspergillus species also varied markedly between different Asian nations, with A. flavus making up around two thirds of Aspergillus in India and over one third in Thailand (compared with only 11% to 19% in other countries). A. fumigatus made up around half of Aspergillus species in Hong Kong and Thailand but was less frequent in other countries.

Rare but emerging molds identified in the study included zygomycetes (most common in India and Thailand), Fusarium (most common in Thailand), Paecilomyces (most common in Singapore) and Scedosporium (most common in Hong Kong, but overall less common than in Australia and other Western countries).

The study shows that significant variations in the fungal burden and distribution of fungal isolates exist in different Asian countries and/or hospitals. This highlights the need to take into account geographic differences when adapting guidelines on antifungal therapy for Asian settings. Finally, this surveillance study may allow for the identification of potential niches for the development of new antifungal agents or new indications of current antifungal agents.

References:1. Sun P-L. Presented at: the 18th Congress of the International Society for Human and Animal

Mycology; 11-15 June 2012; Berlin, Germany. 2. Sun P-L, et al. Mycoses 2012;55(Suppl 4):49.

endemic mycoses in Asia

Professor Arunaloke ChakrabartiCenter for Advanced Research in Medical Mycology & WHO Collaborating Center Postgraduate Institute of Medical Education & ResearchChandigarh, India

Endemic mycoses are a group of diseases caused by diverse fungi that occupy a specific ecologic niche in the environ-ment, are dimorphic in nature and are able to produce infection in healthy hosts. In Asia, pockets of endemicity exist for histoplasmosis, penicilliosis and sporotrichosis – and these can have a significant impact on public health. Notably, the incidence of endemic mycoses has increased markedly in Asia with the rising number of people with HIV/AIDS.1

HistoplasmosisHistoplasmosis is endemic in pockets of Asia but the overall regional endemicity is unknown. Skin test surveys have shown that histoplasmosis occurs in 3% of Malaysian children schooled near caves, 26% of long-term residents

in the Philippines, 19% of those living in China (especially in hospitals in Southeast China), and 0%–12% of the popula-tion living in the Jamuna river valley in India.2

PenicilliosisPenicilliosis occurs mainly in HIV-infected patients in Southeast Asia and Southern China, and is the third most common opportunistic infection after tuberculosis and cryptococcosis in HIV/AIDS patients in Thailand. The disease is also seen in those with hematologic malig-nancies and diabetes. Penicilliosis has similar clinical presentations to histoplasmosis so it can be difficult to diagnose in areas where both occur, such as Southern China.2

sporotrichosisSporotrichosis is prevalent in India, Japan and China, occurring more commonly in areas with temperatures of 26°C–27°C and humidity of 92%–100%. It has been isolated from soil, cornstalks and hay, with transmis-sion from animal to man being reported only once (feline transmission in India). Sporotrichosis causes cutaneous and subcutaneous infection and may occasionally affect the lungs, joints, bones and other sites in predisposed individuals.2

As there are no existing rules or guidelines on reporting infections in Asia, it is difficult to clearly understand the epidemiology of endemic mycoses, according to Professor Chakrabarti. There is also a lack of clinical and laboratory experience in identifying and treating fungal infections in the region. Thus, education and comprehensive epidemiologic studies are required.

References:1. Chakrabarti A. Mycoses 2012;55(Suppl 4):50. 2. Chakrabarti A, Slavin MA. Med Mycol 2011;

49:337-344.

PythiosisPresented by Professor Arunaloke Chakrabarti on behalf ofDr Ariya ChindampornDepartment of MicrobiologyFaculty of MedicineChulalongkorn UniversityBangkok, Thailand

Pythiosis is an emerging and life-threatening infectious disease caused by Pythium insidiosum, which occurs in humans and animals. It is a granulomatous disease charac-terized by cutaneous and subcutaneous lesions and vascular




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diseases. There are three distinct clades of P. insidiosum isolates1,2:• Clade I – isolates from North, Central and South America;• Clade II – isolates from Asia, Australia and the United

States; and• Clade III – isolates from Thailand and the United States.

While human pythiosis is most common in Thailand, a lack of experience with the disease has led to under- diagnosis, delayed treatment and poor prognosis. A retrospective study of 104 infected patients at nine tertiary-care hospitals throughout Thailand from 1985 to 2003 showed that clinical presentations were primarily vascular, followed by ocular, cutaneous/subcutaneous and disseminated cases (Figure). All patients with disseminated infection died, as well as 40% of those with vascular disease who required limb amputation. Thus, this study highlighted the need for early diagnosis and effective treatment to improve clinical outcomes.2

In combination with typical clinical features, serologic methods, such as immunodiffusion and a hemagglutina-tion test, are often used to diagnose and monitor pythiosis. Molecular methods, such as polymerase chain reaction (PCR), may also be used to increase confidence and accuracy of diagnosis.1

Treatment of human pythiosis remains challenging with the currently available antifungal drugs, such as ampho-tericin B, terbinafine and itraconazole, showing limited efficacy. While surgical removal of the infection site can be effective for vascular pythiosis, it often leads to permanent disability and is associated with a high rate of recurrence. Potassium iodide has occasionally been efficacious,

but only with cutaneous disease. In response to a lack of treatment options, immunotherapy with P. insidiosum antigens has been developed, and there is evidence suggesting that this may be a safe and effective method for treating pythiosis in humans.3

References:1. Schurko AM, et al. J Clin Microbiol 2004;42:2411-2418. 2. Krajaejun T, et al. Clin Infect Dis

2006;43:569-576. 3. Wanachiwanawin W, et al. Vaccine 2004;22:3613-3621.


Figure. Clinical presentation for 104 patients with pythiosis diagnosed at nine tertiary-care hospitals across Thailand2

59%33%

3%5%

VascularOcularCutaneous/subcutaneousDisseminated



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Case 1A boy was brought to the skin clinic due to a skin lesion on his left thigh. Tinea was diagnosed based on the evidence of fungal elements on scales. The mother was convinced that their pet dog was the culprit. Three weeks later, fungal culture from scales on the boy’s skin grew an anthropophilic fungus Trichophyton tonsurans. The mother was called back for examination, and tinea was found in her groin area. The child usually sat on her thighs while taking a bath and this was the site where their lesions came in contact. The same fungus was isolated from the mother. No recurrence was noted after both the mother and child were treated. The innocent dog, however, was sent away soon after their first visit to my clinic.

Case 2A young lady was diagnosed to have tinea on her right knee. Fungal culture from lesion scales grew Microsporum canis. She was advised to bring her Persian cat to a veterinary clinic for examination due to the zoophilic nature of the fungus. Several weeks later, a new lesion developed on her neck,

and again, M. canis was isolated. She was very surprised and confused because the veterinarian had told her that the cat was cured. I checked the cat at my clinic and found two hidden scaly patches with

infected hairs on its back. Unsur-prisingly, the culture grew M. canis. This time, the veterinarian gave the right treatment for the cat; the pretty cat lost all its hair and had to take bitter pills. The patient has been free of lesions since.

Case 3An elderly woman had a skin lesion on her ankle. Micro-sporum gypseum, a geophilic fungus, grew from the culture. She was a farmer and had daily close contact with farm soil. She was advised to clean her feet after work. No lesion was noted thereafter.

These three cases illus-trate three different sources of infec-tions. T. tonsurans can transmit from human to human, M. canis from animal to human, and M. gypseum, from soil to human. They have different ecologic niches, thus have different host predilections and trans-mission routes. Nevertheless, without the fungal cultures, it is impossible to trace the underlying infection sources and the infections could recur. Microscopic examination of scales can help in disease diagnosis, but not for identifying the infection source. The fungal elements in the tinea lesions look essen-tially the same (ie, hyaline hyphae) regardless of the causative species. Only through fungal cultures can physicians better understand the disease nature and set up a good treatment plan for patients.

Does fungal culture make a difference in the treatment of tinea? The answer is YES.

Make a fungal culture … Otherwise, you will never know what happened.Dr Pei-Lun Sun

Superficial fungal infection is common in dermatologists’ daily practice. However, doctors rarely make fungal cultures from skin lesions, even after performing microscopic examination of the scales for diagnosis. There may be hundreds of reasons for this, such as a busy clinic, lack of time and facilities, etc. Another far more common reason, which is usually heard from non-dermatologists, is that whether you identify the pathogen or not, the treatment remains the same. Since fungal culture makes no difference in treatment, why should we spend time on it? The argument sounds reasonable, but is it valid?



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www.ees.elsevier.com/mmcr

Copyright © 2013 Asia Fungal Working Group.

This newsletter is made available to the medical profession by the Asia Fungal Working Group. The Asia Fungal Working Group of the International Society for Human and Medical Mycology is supported by an unrestricted educational grant from Pfizer. Editorial development by Weber Shandwick Worldwide. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor; any liability or obligation for loss or damage, howsoever arising, is hereby disclaimed.

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